Hand surgery

SURGICAL

REVIEW

Hand Surgery JOHN J. BYRNE, M.D., Diplomate,

American

Board of Surgery, Boston, Massachusetts

I. INFECTION Micrococcus (Staphylococcus). This group of organisms produces toxins with necrotizing, hemolytic and Ieukocidic properties. CoaguIase-positive organisms are most apt to be pathogenic. They form reIativeIy avascular abscesses containing pus, necrotic tissue and tremendous numbers of bacteria. Because of the reduced bIood suppIy the amount of antibiotic reaching the site of infection is Iimited. Organisms captured in these reIativeIy impregnable foci may persist despite high bIood concentration of the antibacteria agent. Many strains inhibit the action of penicillin. There may be two mechanisms for this inhibitory phenomenon. Some organisms can produce peniciIIinase which destroys peniciIIin, and others appear to eIaborate an essential growth factor whose production is bIocked by penicil1in.l Besides the IocaI pyogenic manifestation this organism may spread by bIood stream invasion, producing either a fuIminating or chronic infection. In the fuIminating type there is a high temperature and puIse rate with profound toxemia. The usua1 systemic infection, however, runs a chronic course and is accompanied by metastatic abscesses in the Iungs, kidneys, Iiver, spIeen, heart and bones. Surgical incision stiI1 plays a major roIe in eradicating these infections, but antibiotic therapy is necessary. For IocaI appIication bacitracin in concentration of 1,000 units per cc appears to be of most value. For systemic therapy one may choose between peniciIIin, streptomycin, terramycin or erythromycin, depending on sensitivity studies. Bacitracin may be used parenteraIIy if the daily fluid intake is at Ieast 2,500 cc.l Streptococcus. The classification of this organism depends on antigenic substances and

ROPER

treatment of infection in the hand a knowledge of the causative orits anatomic localization and some ganism, genera1 principIes of treatment.

P demands

BACTERIOLOGIC FACTORS

The causative organism should be determined in every case by use of aerobic and anaerobic c$tures as a basis for correct chemotherapy. Cultures should be repeated periodically in order to detect changes in the bacteria1 flora consequent to secondary contamination or antibiotic therapy. Exposure of bacteria to an antibiotic agent may Iead to the deveIopment of resistance to this antibiotic. Because of the indiscriminate use of various antibiotics by the medica profession, this problem is increasing. For exampIe, Meleney found that 17.8 per cent of coaguIasepositive StaphyIococcus aureus strains were resistant in I 947-1948, whereas in 194 1 this resistance percentage rose to 43 per cent.’ In vitro sensitivity tests are vaIuabIe in discovering such resistance, so that a proper choice of antibiotic may be made. When more than one organism is present in an infection, a mixture of antibiotics may be used as determined by cuIture and sensitivity studies. .However, caution must be taken in administering these combinations since some antibiotics are synergistic to each other and some are antagonistic. In generaI, synergism exists between two members of the bactericida1 antibiotics (penicillin, bacitracin, streptomycin, poIymyxin B, neomycin) or between two members of the bacteriostatic group (aureomycin, terramycin,@chIoromycetin@). Antagonism may occur when a member of the bactericida1 group is administered with one of the bacteriostatic group.2 431

Hand Surgery strated in Figure IA. It was beIieved that this was a severe pyogenic infection, and accordingly peniciIIin therapy was instituted and an incision made. The incision reveaIed no pus, and a specimen was sent for culture. The infection continued to spread until, approximateIy five days after entry, it involved the dorsum and voIar aspect of the wrist and lower forearm as demonstrated in Figure IB. At this time symbiotic infection was diagnosed and bacterioIogic studies reveaIed the presence of enterococci, Staph. aureus, Aerobacter aerogenes, Bacillus proteus. CuItures were sent not only to our own h&pita1 Iaboratory but also to the Iaboratory of Dr. Chester Howe to attempt to uncover microaerophiIic streptococcus. Aureomycin was instituted intravenously for approximately five days. LocaIized phIebitis deveIoped at the site of each aureomycin infusion. Infection continued to spread along the forearm on the voIar and dorsal surfaces and into the palm and dorsum of the hand as demonstrated in Figure IC. The treatment so far consisted of wide surgical egcision, but it was decided to try parentera bacitracin. This had to be stopped in approximateIy four days when the non-protein nitrogen rose to a high level and protein casts were found in the urine. The IocaI agent applied to the excised area was hydrogen peroxide aIternating with bacitracin soIution. At this stage sensitivity studies, performed by Dr. Chester Howe, reveaIed the organisms to be sensitive to a combination of streptomycin and suIfamyIon.@ Following wide excision of the infected area, the wound was dressed with an occIusive dressing under which multiple catheters were applied, and through which the streptomycinsuIfamyIon mixture could be injected at numerous intervals during the day so that a high concentration of this agent wouId be present continuously. Using this approach, the infection appeared to be controIIed with a complete denuding of the skin and fascia from the elbow down to the metacarpophalangeal joints of the fingers invoIving many of the extensor and Aexor tendons. The invoIved area began to granuIate and split-thickness skin grafts were applied to the granuIating areas. Approximately four weeks following entry a simiIar process deveIoped in the right arm at the site of the intravenous aureomycin infusion (Fig. ID) and over the right deltoid muscle at the site of the peniciIIin injection. These areas progressed in spite of wide surgica1 exci-

the abiIity to hemolize blood. Group A, betahemolytic strains produce a great majority of streptococca1 disease in man, with occasional strains in group C and G being responsible. These three groups produce fibrinolysin, desoxyribonucIease, hyaluranidase and erythrogenie toxin. The non-hemolytic streptococci are usualIy secondary invaders and usualIy produce a chronic disease. The anaerobic strains of streptococcus will be discussed later. The genera1 pattern in hand infections is celIulitis with Iymphangitis and Iymphadenopathy associated with fever and toxic symptoms. The organisms may enter the blood stream and metastasize to joints, Iungs, kidneys, spIeen, liver, brain and skin. The endotheIiaI-Iined cavities, such as pIeura, pericardium, peritoneum and meninges, may aIso become invoIved. PeniciIIin is the antibiotic of choice for the hemoIytic streptococci. The nonhemoIytic organisms, incIuding enterococci and viridans, may be resistant to this drug and require other antibiotics chosen by sensitivity studies. of Symbiotic Infection. The combination micro-aerophiIic non-hemoIytic streptococcus and hemoIytic staphyIococcus aureus produces a destructive Iesion of the skin and subcutaneous tissue. The lesion is usuaIIy painful and tender, and the gross appearance is quite characteristic. There is an outer zone of erythema varying from I to 2 cm. in width, a dark purple sharpIy defined middIe zone and an inner zone of gangrenous skin. The inner margin is onIy slightly undermined but graduaIIy melts away as the whoIe Iesion spreads centrifugaIIy. The center of the Iesion becomes a granuIating ulcer, which in time may become bright red and clean. The disease continues to spread unti1 the patient dies or the infection is brought under contro1. Chemotherapy is of IittIe avail although Meleney beIieves that bacitracin is the drug of choice.3 The usua1 treatment is wide surgical excision pIus the antibiotics which are effective against the causative organisms as demonstrated by sensitivity tests. Activated zinc peroxide may occasionaIIy be beneficia1. A recent tragic experience with this infection is noteworthy: Mr. F. (Boston City Hospital No. 1415513) was a fifty-nine year old white man who sustained a compound fracture of the right thumb whiIe at work. The wound was sutured elsewhere. Five days Iater on entry to the Boston City Hospital it appeared as demon-

432

Surgical

Review

FIG. 1. Symbiotic infection. A, compound fracture, Ieft of severe infection. B, spread of infection from thumb injury. D, devefopment of symbiotic infection at site following initial injury. E, spread of symbiotic infection to right wrist, with involvement of underlying fascia previous infection in Ieft forearm. H, spread of symbiotic infection.

sion and Iocal chemotherapy consisting of streptomycin and suIfamylon (Fig. IE) unti1 the entire right upper extremity from the deItoid to the wrist was denuded of skin and fascia. (Fig. IF). Six weeks foIIowing entry, whiIe the right and left arms were progressing as described, massive biIatera1 deep phIebitis of the Iower extremities deveIoped with resultant edema from the knees to the toes. No definitive treat-

thumb, five days folIowing injury with deveIopment to wrist. C, spread of infection three weeks following of aureomycin injection, right forearm, four weeks in right arm. F, spread of infection from right deltoid and tendons. G, skin grafts healed we11 over site of infection to both groins five months foIlowing initia1

ment was instituted for the phlebitis. AnticoaguIants were contraindicated because of the extensive uIcerating area, and a surgica1 attack in the groins couId not be done for fear of spread of infection to this area. During the ensuing months of hospita1 stay the edema gradually subsided and no puImonary emboli were noted. FinaIIy, after numerous excisions and ultimate skin grafting, the disease appeared to be 433

Hand Surgery checked about five months following entry and the extremities were covered with skin. Figure IG shows the Ieft arm now compIeteIy covered with spht-thickness skin grafts. However, whiIe convalescing from these infections a patch of redness was noted in the Ieft groin which progressed to a similar type of infection in this area that uItimateIy spread to the right groin. Figure IH shows the patch of symbiotic infection in the Ieft groin involving skin and fascia with the onset of infection in the right groin. WhiIe surgery was being contemplated for this condition, the patient died suddenIy in a compIeteIy cachectic state. This case raises many issues. Correct debridement and care of the initia1 injury shouId have prevented this infection in the First place. SecondIy, the absence of micro-aerophiIic streptococcus on repeated examination of cuItures by two bacteroIogic Iaboratories is of interest. Staph. aureus was the predominant organism which was occasionaIIy mixed with the various bacteria such as BaciIIus pyocyaneus, B. proteus and enterococci. This is simiIar to the experience of WiIson. 4 Thirdly, the reason for the spread of this infection to the opposite arm and both groins is not cIear. The invoIved sites were a11 areas of previous skin punctures. However, numerous brachia1 blocks were performed without subsequent IocaI infection. It may be that greater care was taken to steriIize theskin before the brachia1 bIocks than before the routine venipunctures and injections. The phIebitis in the right arm and both Iegs with its attendant edema may have produced an area of decreased tissue resistance. It is we11 known that such edematous areas are more Iiable to infection than norma areas. WiIson has recentIy reported a series of somewhat simiIar cases caIIing this disease “necrotizing fasciitis.” HemoIytic staphyIococcus was the most frequent offending agent in this series. The name is derived from the fascia necrosis which is a consistent manifestation of the disease. For surgica1 excision WiIson lifts skin flaps off the underIying invotved fascia, removes the purutent and necrotic fascia for the entire extent of its undermining and then permits the skin flaps to return to their origina position. In this way he prevents tremendous skin Iosses which are the resuIt of the older methods of treatment.4 It seems to the reviewer that this is a very worth while suggestion. The buman bite is another symbiotic infection 434

in which the anaerobic streptococci are the most significant organisms. These Iesions aIso contain pathogenic actinomycetes, fusiform baciIIi and spirochetes. When the bite invoIves the metacarpophaIangea1 joint, the anatomy predisposes to entrapment of the organisms in the joint.s Therapy consists of soap and water cIeansing of the wound for twenty minutes; irrigation with sterile saline soIution; Ieaving wound open to heal by secondary intention; applying a sterile dressing; splinting the hand in a position of function; instituting antibiotic therapy. AIthough most surgeons use penicillin as the antibiotic agent, Levin and Longacre found exceIIent results with bacitracin in conjunction with the other genera1 methods of treatment. It is the belief of those on the Boston City Hospital Hand Service that when the metacarpophaIangea1 joint is invoIved and the wound seen earIy, the joint shouId be opened by means of two lateral incisions, irrigated and left open. A drain may be left in the wound, taking care that it does not enter the joint space but mereIy keeps the skin edges and underIying tissues separated. Mycobacterium tuberculosis. This organism may infect tendon sheaths, bones and joints. The tenosynovitis is of;+speciaI interest and is seen in people who wo$k with cattle (miIkers, skinners, butchers, etc.). It is caused by direct extension of an infection in the hand, or it may be secon’dary to putmonary tuberculosis. Trauma may be a predisposing factor. The third and fourth decades are the most common age groups invoIved. The pathoIogy of this disease is the same as other types of tubercuIosis. It affects the synovia first, and at a Iater date it involves the tendon and surrounding structures. The voIar tendons are twice as frequentIy involved as the dorsa1 ones, and the right upper extremity is aflicted more than the Ieft. There is a sIow onset of a reIativeIy painIess sweIIing over the invoIved tendon or tendons with eventua1 Iimitation of function. At first the sweIIing is doughy in consistency, but as the disease progresses it may become IIuctuant. When it invoIves the ulnar bursa, it presents deformity with a conff uent an “hour-glass” mass in the paIm and forearm (compound gangIion). The semi&id mass may be pressed back and forth under the voIar carpal ligament. If rice bodies are present, crepitus may be felt.

Surgical

Review

UsuaIIy there are no genera1 signs of disease unti1 late in the process. Treatment consists of complete excision of the invoIved parts (Fig. 2) pIus immobilization in a pIaster cast and a course of treatment with streptomycin and para-aminosalicylic acid for approximateIy six weeks. BickeI et aI.7 in a foIIow-up study of thirty patients operated upon at the Mayo CIinic found exceltent resuIts in eight cases, good in eIeven cases, fair in four cases and seven faiIures which required subsequent surgery on tendons or joints. OccasionaIIy a tubercuIous infection of the skin of the fingers wiI1 occur if there is an abrasion or cut which can become infected. Doctors and nurses who work with tuberculous patients are particuIarIy IiabIe to deveIop this chronic ulcerating lesion. Girdwood* caIIs attention to Jtingling’s disease or muItipIe cystic tuberculosis of bone. There is a gradual onset of sweIIing in a smaI1 bone of the hand or foot which may be moderateIy painfu1. X-ray shows a cystic trabecuIated expansion of the bone. The disease takes a sIow course tending to spontaneous improvement and even recovery. Treponema pallidum. This organism rareIy invoIves the hand, but chancres may occur at the site of a hangnail and be mistaken for paronychia. Tertiary Iues may affect the tendon sheaths, bones and joints of the fingers and wrist. Discussion of the treatment of this condition is beyond the scope of this review. Pasteurella tularensis. This organism produces infectious disease in rodents and in other wild and domesticated animaIs such as game birds and domestic chickens. Man becomes infected with this organism when he is bitten by an insect vector (tick or deer fly) or when he comes in contact with diseased animals. If the source of entry is the skin of the hand, a papuIe-like lesion deveIops which Iater ulcerates. A red granuIoma occurs with a surrounding zone of ceIIuIitis. Later, the center of this becomes necrotic Ieaving a punched-out ulcer. Bacteria spread aIong the Iymphatics with resultant Iymphangitis and Iymphadenitis. In half the cases the glands suppurate. Septicemia may deveIop with foci of infection in the spleen, Iiver, lungs, Iymph nodes, bone marrow or other tissues. Identification is made by bacteria1 smear, direct culture, inocuIation in guinea pigs and the Foshay intraderma1 test. Positive bIood cultures may be obtained during

FIG. Z. Tuberculous tenosynovitis of left wrist showing infected tissue being dissected from underlying tendons.

the first week, and aggIutinins are demonstrabIe after ten days. Streptomycin is effective in eradicating this disease. There is some evidence that aureomycin and chloramphenicol are effective. Bacillus antbracis. This aerobic spore-forming organism causes disease in sheep, cattIe, horses and swine. Human infection develops from handIing such animaIs on the farm or from manufacturing and processing their products in the factory and canneries. A red macuIe deveIops that enIarges and produces a vesicle which ruptures, Ieaving a characteristic black gangrenous base. There may be surrounding vesicIes. The lymph glands wiI1 become enIarged and tender with associated maIaise and fever. The disease may produce septicemia with subsequent pneumonia, endocarditis and meningitis. Diagnosis is obtained by inocuIation of mice with subsequent culture of the organism and observation of a Giemsa-stained smear of the spleen. OccasionaIIy a direct microscopic examination of a smear from the Iesion may give a tentative diagnosis. AggIutination tests with B. anthracis are not satisfactory. Penicillin therapy appears to be very effective. Malleomyces mallei. This organism produces a rare disease in which the infected mucus from horses, muIes or donkeys enters an abrasion of the hand causing an initia1 Iesion that is called “farcy.” A granuIomatous Iesion develops which uIcerates and becomes encircled by smaI1 vesicIes and pustuIes with associated Iymphangitis and Iymphadenitis. The uIceration may spread into the muscles, or infection may spread to the Iungs, perito435

Hand Surgery neum, skin, joints and bones. Diagnosis is by smear, cuhure and guinea pig inoculation. There is aIso a subcutaneous mallein test, an aggIutination test and a compIement-fixation test. Neisseria gonorrboeae. This produces tenosynovitis of various tendon sheaths or arthritis of the wrist and finger joints. The acute tenosynovitis may be diffrcuIt to diagnose from an ordinary pyogenic infection. The diagnosis is by smear and cuIture of the infected tissue. PeniciIIin is the antibiotic of choice. Erysipelotbrix rbusiopatbiae. This organism is found in a wide range of animaIs and produces the swine erysipelas. It survives in decomposing nitrogenous material and is often found in decomposing fish, sheIIfish or meat. It produces infection in man by penetrating the skin of the hand through a wound or abrasion. This is most commonly found in abattoir workers and fish handIers.g There is severe erythema and edema of the part with pain persisting in the affected area. The infection is self-Iimited and seIdom goes beyond the wrist. ReIapses are common and occasionally a generalized septicemia with infection of the endocardium and joints may occur. Diagnosis is by biopsy and cuIture. The treatment is conservative since it is usuaIIy self-Iimited. PeniciIIin appears to be the antibiotic of choice.‘O Actinomyces bovis. FrequentIy cattIe, swine or horse workers may be invaded by this organism through an abrasion or wound of the hand. There is a granuIoma simiIar to that of tuberculosis which wiI1 remain for months as an indolent noduIe with occasiona sinus formation. It may cover the entire dorsum of the hand. Diagnosis is made by microscopic examination and culture of the draining materia1. PeniciIIin and aureomycin may be of benefit in treatment. Isoniazid (nydrazid@) has recentIy been reported as beneficia1.” Blastomyces dermatitidis. Infection of an abrasion or wound of the hand by this organism produces a papuIopustuIe which spreads peripheraIIy. The center may hea1, Ieaving a scar surrounded by a spreading border. A systemic type of disease beginning in the Iungs with a hematogenous spread to the skin and bones may occur. Diagnosis is made by smear and culture of the draining material. Iodides and x-ray have been advised for treatment. Sporotricbum scbenkii. This wideIy distributed fungus may infect the extremities

through abrasions or thorn pricks. A pustule or abscess develops with invasion of regiona Iymphatics producing a thickening of the lymph vesseIs with multipIe granuIomas along the course of these vessels which may rupture spontaneousIy. Diagnosis is made by examination and culture of the draining material. Treatment with iodides may be of vaIue. Coccidioides immitus. This organism rarely affects the hands. When it does, it causes skin nodules or uIcers. Diagnosis is made by examination of smear and cuIture. Monosporium apiospermum. This organism which causes madura foot occasionally affects the hands, giving rise to a granuIomatous Iesion similar to actinomycosis. Diagnosis is made by smear, cuIture or biopsy. Although antibiotics are of IittIe value, they may prevent secondary infection. ANATOMIC

LOCALIZATION

Suppuration in the hand must be treated by incision and drainage. Knowledge of the various anatomic spaces is essential for this purpose. Incisions must be placed to drain pus adequately, but they should avoid tactiIe surfaces of the fingers and palm whenever possible. They shouId aIso avoid crossing ffexion Iines of fingers or paIm and shouId not damage underIying structures. Pulp Spaces. A felon is an abscess of the puIp space of the terminal digit manifested by a painfu1, swoIIen, indurated and tender fingertip. If not treated early, osteitis and skin necrosis may occur. The skin necrosis not only results in a deformed distal phaIanx but aIso greatly increases the heaIing time. Extension of the infection shuts off the blood suppIy to the diaphysis of the terminal phaIanx causing aseptic necrosis of bone which may become secondariIy infected. Bolton et aI.‘* chaIIenge this concept of occlusion of the digital vessel and beIieve that bone invoIvement is due to direct extension of infection to the periosteum. ProbabIy both mechanisms pIay a role in producing osteitis. X-ray evidence of osteitis is of prognostic vaIue. Robins13 found the heaIing time of simpIe feIons to be ten days; whereas if osteitis was present, the healing time was thirty days. Treatment consists of wide excision around the end of the tinger taking care that the incision passes aImost underneath the nail.

Review

Surgical (Fig. 3.) The usuaI textbook of surgery demonstrates this incision carried across the tip of the finger rather than dorsal to it. This may not 0nIy Ieave a painfu1 scar in an important tactiIe area but aIso may resuIt in a deformed fingertip due to sIoughing of the skin dorsa1 to

FIG. 3. Incision of felon. (a) Anterior incision shouId be pIaced close to naiI to avoid scar on tactile surface. (b) Incision should be carried through a11 fibrous septa of dista1 pulp space.

FIG. 4. PoorIy pIaced incision for feIon producing formed fingertip.

de-

age. The other infection is a subepitbelial abscess in which the underIying pus can be seen through the thin waI1 and requires mereIy an unroofing without anesthesia. It may mask an underIying deep abscess, in which case a sinus tract can be demonstrated. SimiIar infections can occur in the puIp spaces of the proxima1 and middIe pharanges and must be surgicaIIy drained. One incision is a right angIe one which is carried through the digita crease and extended aIong the Iateral aspect of the finger. When infection is present in the puIp space of the proximal phaIanx of the finger, IseIin16 suggests making an incision which is carried aIong the IateraI aspect of the fmger to the web space which is then compIeteIy opened by an anterior-posterior incision. This may result in an adduction deformity. Paronycbia. They begin in one portion of the paronychium or eponychium, and treatment consists of a simpIe incision of the abscess. When Ieft untreated, however, they may run compIeteIy around and under the nai1 as a “horse-shoe” shaped abscess. Drainage must then be accompIished by Iifting a flap of eponychium and removing the proxima1 haIf of the nai1. In deveIoping the eponychia1 flap, two incisions are made at the lateral angIes of the nai1 bed dista1 to the IunuIa so as to avoid damaging the nai1 matrix. They are extended IateroproximaIIy. (Fig. 5.) Chronic paronychia shouId make one suspicious of fungus infections which are quite

the incision. (Fig. 4.) The fibrous septa, from skin to periosteum, must be cut through compIeteIy and aI1 necrotic tissue excised. If loose bone is found in the puIp, it shouId be removed. If the wound does not hea in severa weeks, the possibiIity of sequestration shouId be entertained and additiona x-rays taken. If sequestration is found, it can be remedied by surgery. Scott and Jones’4 have reviewed their experiences with excision of necrotic tissue and primary suture as a method of treatment of surgical infections of the hand. Primary healing occurred in $6 per cent of 226 felons, with an average healing time of eIeven days. The average heaIing time of the other cases was thirtyfour days. It is difflcuIt to see the advantages of this method of treatment, since in Robins’ series of 197 feIons in which a conventional “hockey-stick” incision was made, the heaIing time was ten days for simpIe cases, fifteen days with skin necrosis and thirty-two days with osteitis.13 In other words, when primary healing takes pIace by this immediate suture method, the average healing time is about the same as for the standard drainage methods. If it does not occur, heaIing time is proIonged. Two other infections of the dista1 phaIanx may occur which are not as serious as true felons. One is the apical abscess which lies in the dista1 puIp space under the nai1 bed and anterior to the phaIanx. I5 Osteitis seIdom occurs with this, and hence the average heaIing time is short. Treatment consists of remova of skin and distal portion of nai1 to provide free drain437

Hand Surgery common in peopIe whose hands are frequently

or direct spread. Infection may also extend to the proxima1 phalanx or aIong the IumbricaI canal to one of the palmar spaces. If the abscess is confined to the paImar surface, a smaI1 curving incision over the interspace wiI1 be sufficient. (Fig. 6A.) However, with dorsa1 extension, a IongitudinaI incision on the dorsum of the web space may be necessary. (Fig. 7A.) The web shouId not be incised compIeteIy since this might lead to an adduction contracture of the fingers. Occasionally, persons dealing with hair or hides develop Iesions produced by short hairs working into the skin and stimulating a foreign body reaction. In the dairy industry these are known as “miIker’s granuIoma.” Downing17 has reported such a Iesion resembling a pi,IonidaI sinus appearing in the web space of barbers. Superficial Palmar Fat Pads. In the palm

immersed

in water. Web Spaces. In the web spaces between the fmgers, compartments are formed which are bounded on either side by the pretendinous paImar fascia bands, proximaIIy by the super-

0

l3

FIG. 5. Incision of paronychia. (a) Lateral incisions shouId begin distat to Iunula. (b) ProximaI haIf of nai1 removed after eponychial flap is raised.

6 FIG. 6. Incisions for draining infections of the hand. A, web space; B, midpaImar; C and C’, quadriIatera1 space of the forearm; D and E, digita tenosynovitis; F, radial bursa; G, ulnar bursa. FIG. 7. Incisions for hand infection. A, web space; B, thenar space; C, dorsal space.

ficia1 transverse paImar Iigament, distaIIy by the natatory or intradigita1 Iigament, and overIain voIarIy by a smaI1 fat pad. The web space contains the digita nerve and arteries and the IumbricaI muscIe. The tissue in this space is the common site of infection from skin abrasions, caIIuses or splinters. The infection points to the palmar aspect of the web space but may spread dorsaIIy by Iymphatic invasion

of the hand there are fat pads over the thenar and hypothenar eminences which may be the site of an-abscess. These may be confused with some of the more important paImar spaces. Treatment is incision over the area of fluctuation. Tbenar

and

Hypotbenar

Muscle

Spaces.

The fascia covering the hypothenar and thenar muscle groups forms potential spaces which 438

SurgicaI

Review palm. Clinically there is a central swelling of the palm with well marked lateral limitations. There is the usual red edema of the dorsum of the hand. This space may be drained by a transverse incision in the palm paralleling the proximal palmar crease. (Fig. 6B.)

may be the site of abscesses. These are drained by suitable incisions over the area of maximum tenderness and IIuctuation. Care must be taken to drain the thenar muscle space abscess at some point distant from the motor branch of the median nerve. This point has been well

n

m?norf Eminence FIG. 8. Schematic cross section of palm. of hand. A, pretendinous Iselin; B, mid-paImar space; C, thenar space.

described by Kaplan’8 using the cardinal line as a landmark. This line is drawn from the apex of the interdigital fold, between the thumb and index finger, paraIle1 with the middle crease of the palm of the hand, passing near the distal pole of the pisiform bone. The intersection of this line with the thenar crease corresponds to the underlying motor branch of the median nerve. Palmar Space. The palmar space is bound laterally by the thenar and hypothenar eminences, dorsally by the interosseus muscles and fascia, voIarIy by the palmar fascia, proximaIIy by the apex of the palmar fascia where it joins the transverse carpal Iigament, and distally where the palmar fascia ends as pretendinous bands to the fingers or at the superficia1 transverse ligament just proximal to the web spaces. In this compartment lie the flexor tendons to the four fingers surrounded by the ulnar bursa as we11 as the digita nerves, vesseIs and, lumbrical muscles. This ulnar bursa with enclosed tendons divides the palmar space into a pretendinous space and a retrotendinous space. The pretendinous palmar space has been we11 described by IseIin.16 Figure 8A demonstrates this space on transverse section of the

space of

There has been great controversy concerning the retrotendinous palmar space. Most authorities agree that it is divided into two by a septum of fascia arising from the undersurface of the llexor tendons and attached to the entire length of the middIe metacarpal bone.rg KapIanI believes that this septum is formed by the adherence of the uInar bursa to the interosseus and adductor fascia in the region of the crest of the third metacarpa1 where the transverse fibers of the adductor pollicis muscle take origin. Regardless of the origin of this septum, it divides the retrotendinous compartment into the middIe paImar and the thenar paImar spaces of KanaveI. *a Figure 8B and C demonstrates these compartments in a transverse section of the palm. A fat pad is almost universaIly present in the mid-paImar space of the hand which may be a reason for the vuInerability of this space to infection.18 The mid-palmar space abscess is manifested by swelIing and tenderness in the central palm. The third, fourth and fifth lingers may be held in partia1 flexion and there is the usual dorsal edema associated with severe hand infections. It may be drained satisfactoriIy by a transverse incision through or paralIe1 to the distal transverse paImar crease. (Fig. 6B.)

439

Hand Surgery

FIG. 9. Tenosynovitis of right index tinger ing character&tic position-of finger.

demonstrat-

FIG. IO. Incision finger.

The thenar space should not be confused with the thenar muscle space. Since the floor of the thenar space is the adductor pollicis muscle and fascia, it is beIieved that a better term for this space would be the “adductor space.” Infection in thi; area may extend around the free border of the adductor muscIe to the dorsum of the web space between the thumb and index finger resembling a web space infection. A thenar space abscess presents tenderness and sweIIing over the thenar portion of the paIm with much edema in the web space between the thumb and index finger. There is usuaIIy partial Aexion and limitation of motion of the index finger, and the thumb is heId in abduction. This space is drained by an incision in the web space of the thumb on the dorsa1 aspect paraIIe1 with the anterior surface of the second metacarpal bone. (Fig. 7B.) The first dorsa1 interosseus muscle is retracted uInarIy and dissection is continued along the course of the adductor poIlicis muscIe unti1 pus is reached. Dorsal Spaces. There are two dorsal spaces in the hand: the subcutaneous space between the skin and the extensor tendons and their and the dorsa1 subintertendinous fascia, aponeurotic space between the extensor tendons and the metacarpal bones and interosseus muscIes. Either space may be drained by a Iongitudinal incision, taking care to avoid the underIying tendons. (Fig. 7C.) Carbuncles occur most frequentIy on the dorsum of the first phaIanx of the finger, aIthough they may appear anywhere on the . ’ hand. Th e prmcrpIes of treatment of carbuncles in other parts of the body are applicabte

for tenosynovitis

of right

index

to the hand. With modern chemotherapy surgery is usuaIIy Iimited to minor incisions of pyogenic cavities. X-ray may help in localizing the infection. Beware of diabetes ! Quadrilateral Space qf tbe Forearm (Parona). This space is bound dorsaIly by the pronator quadratus muscIe and the interosseus membrane of the forearm, voIarly by the flexor digitorum profundus tendons; radially by the flexor carpi radialis, and uInarIy by the flexor carpi ulnaris. DistaIIy it communicates with the carpal canat where it has a reIation with the radial and uInar bursae. Infection may spread to the quadrilatera1 space from the paImar spaces or from the radial and ulnar bursae. CIinicaIIy, there is sweIIing and tenderness of the entire voIar aspect of the forearm. The abscess may be drained by a Iongitudinal incision paraIIe1 with the media1 borders of the radius or uIna, taking care to avoid the underIying structures. (Fig. 6C and C’.) Tendon Sbeatb. A knowledge of tendon sheath anatomy is a basic requirement for correct surgical treatment of tenosynovitis. The tendon sheaths of the index, middIe and ring fingers extend from the insertion of the flexor profundus tendon in the distal phaIanx to thr mid-palmar creases. The tendon sheath of the thumb begins at the insertion of the flexor poIIicis Iongus tendon in the distal phaIanx and extends into the wrist through the carpal cana1. The extension of this tendon sheath into the paIm is called the “radia1 bursa.” The tendon sheath of the fifth finger extends from the insertion of the profundus tendon in the dista1 phaIanx to the wrist under the carpal tunneI. The portion of this tendon sheath in 440

Surgical the palm is called the -“ulnar bursa” and it enlarges to invest all the flexor tendons of the fingers. The uInar bursa is arranged in three communicating compartments: superficial, anterior to the tendon of the flexor sublimis; middle, between the tendons of the sublimis and profundus; posterior, dorsal to the tendon of the flexor profundus. The Iumbrical muscles are outside of the ulnar bursa. This arrangement is present in approximately 70 per cent of investigated cases.*l The cardina1 points of digital tenosynovitis which have been emphasized by KanaveIzO are: tenderness over the invoIved tendon sheaths, pain on hyperextending the finger, ffexion deformity of the involved finger and sweIIing of the invoIved part. Figure 9 demonstrates a typica case of digita tenosynovitis. In order to distinguish tenosynovitis from subcutaneous ceIIuIitis, Mosesz2 uses the foIIowing test: “The nail of the involved finger is fixed by the examiner so that actua1 flexion wiI1 not be allowed. The patient is then to attempt ffexion and if tenosynovitis is present, this wiI1 cause pain. Since, however, the finger does not move, a ceIIuIitis wiI1 not produce pain.” Tenosynovitis shouId be incised as early as possibIe in the course of the disease. In the finger the moti useful incision is a mid-lateral one, extending the entire Iength of the finger. The ends of the digita creases serve as Iandmarks for the IateraI pIane of this incision. (Figs. 6D and IO.) It is also necessary to make a curved incision over the paImar cuI-de-sac of the tendon sheath. (Fig. 6E.) When the radial bursa is invoIved, there wiI1 be the usua1 signs of tenosynovitis in the thumb associated with tenderness along the course of the bursa. In addition to the usua1 digita incision on the thumb, the bursa may be drained by a curved incision over the uInar aspect of the thenar eminence taking care to avoid the underlying motor branch of the median nerve. (Fig. 6F.) If the volar carpal Iigament -must be incised to drain this tendon adequately, it must be opened on its IateraI side rather than in the middIe to avoid proIapsing of tendons. The cul-de-sac of the radia1 bursa in the wrist is found and drained through a IongitudinaI incision immediateIy ulnar to the dista1 3 inches of the flexor carpi radialis. (Fig. 6C’.) Infection in the ulnar bursa presents a sweIIing on the paImar and dorsal surfaces.

Review There is tenderness along the course of the tendon sheath of the fifth finger and aIong the ulnar bursa. There may be tenderness just proximal to the transverse carpal Iigament in the wrist. AI1 the fingers are heId semi-flexed and pain is produced on attempting passive extension. There is limitation of motion of the wrist. The incisions to be used in opening this infection are a mid-IateraI incision aIong the fifth finger, a curving paImar incision which just skirts the hypothenar eminence (Fig. 6G) and an incision just radia1 to the distal 3 inches of the uIna. (Fig. 6C.) The fascia of the forearm is incised in Iine with the forearm incision, and the flexor carpi uInaris is retracted radially. The pronator quadratus muscIe is exposed, and lying on its distal portion is the bulging cul-desac of the ulnar bursa which is incised. If the bursa has ruptured intp the quadrilateral space of the forearm, a counterincision is made on the opposite side of the forearm. Joint Spaces. These spaces may become infected by trauma, spread from neighboring infections or metastasis. The most common organisms are streptococcus, staphylococcus and rareIy gonococcus. The interphalangeal and metacarpopbalangeal joints have a fairIy similar pattern of anatomy. Each possesses a capsule which is reinforced IateraIIy by the IateraI coIIatera1 ligaments running in a voIar direction from the proximal bone to the distal bone. The volar aspect of the joint is reinforced by a strong ligament known as the “voIar accessory ligament” or the “paImar pIate.” The fibrous tendon tunnels adhere to the paImar plates. The dorsum of the joints are reinforced by various portions of the extensor mechanism, the distal interphaIangea1 joint being reinforced by the termina1 insertion of the extensor apparatus of the fmger and the proxima1 interphaIangea1 joint being reinforced by the central extensor tendon and IateraI band. KapIan18 found loose connections present in the metacarpophaIangea1 joint between the extensor apparatus and the dorsa1 aspect of the capsuIe in 38 per cent of a series of cases. Infection in the digita and metacarpophaIangea1 joints may present sweIIing, redness, tenderness, excessive mobility and crepitus. X-ray wiI1 reveal the disease by the second or third week when decalcification and erosion of the joint line may be seen. When the infection spreads beyond the joint, it tends to spread dorsoIateraIIy since the capsuIe is most thin

Hand Surgery at this point. RareIy, the infection may spread anteriorIy into the flexor sheaths, particuIarIy at the proxima1 interphaIangea1 joint. Treatment is by chemotherapy, surgical incision and immobilization in the position of function. Usually two latera incisions over each joint are sufficient for adequate drainage. Motion should be started as soon as the infection has subsided. The wrist incIudes the folIowing joints: the distal radio-ulnar, radiocarpal, proximal intercarpal, dista1 intercarpal, mid-carpa and carpometacarpal. The more important joints are the radiocarpal and the mid-carpal through which most of the motion in the hand occurs. KapIanr8 has summarized the motions of the wrist approximately as foIIows: “. . . volar flexion of the hand takes pIace mostly in the radio-carpa joint and secondarily in the midcarpa joint. Dorsiffexion, on the contrary, occurs mostly in the mid-carpa joint and additionaIIy in the radio-carpal joint. RadiaI deviation occurs mostly in the mid-carpa joint, and uInar deviation occurs mostIy in the radio-carpa articutation. Infection of the wrist joint is demonstrated by sweIIing, pain and tenderness in the region of the wrist. A persistent sweIIing on the dorsum of the wrist is fairIy pathognomonic. Crepitus in this joint is a late manifestation. X-ray taken during the second or third week of the disease wiI1 show disintegration of the carpa bones. The principles of treatment are the same with the wrist joint as in the other joints. The incision is usuaIIy performed over the uInar side of the wrist as recommended by BunneII.23 Through a IateraI incision over the joint, the tendons of the ffexor and carpi uInaris are severed at their insertions. The wrist joint can be widely opened by cutting the joint capsule, and necrotic carpa bones removed if necessary. The head of the uIna should be removed to permit pronation and supination. Immobilization should include the upper arm to prevent supination and pronation. The position of the wrist shouId be mid-way between supination and pronation with about I 3 degrees dorsiff exion. Lymphatic System. The superficial coIIecting Iymphatics of the fingers continue laterally to the base of the fingers where they pass through the interdigita1 cleft to reach the dorsum of the hand.24 The Iymphatic trunks of the palm pass in four directions: inferiorly,

into the web space of the Iinger to ascend on the dorsum of the hand; IateraIIy and mediaIIy, around the border of the hand to unite with the Iymphatics on the dorsum of the hand; superiorly, toward the anterior surface of the forearm. The coIIecting trunks of the dorsum of the hand continue upward aIong the posterior surface of the forearm, and they incline toward their adjacent borders of the forearm just above the wrist. The Iateral coIIecting trunks, from the thumb and index finger, and the medial coIIecting trunks turn around their adjacent borders of the forearm and continue up the arm aIongside the anterior collecting trunks from the palm of the hand. The medial, anterior and IateraI coIIecting trunks of the forearm continue aIong the anterior surface of the arm to terminate in the axillary nodes chiefly in the axiIIary vein group and in the central group. A few of the lateral coIIecting trunks in the upper part of the arm course along the cephalic vein and deltopectoral SUICUS to terminate in the subcIavicuIar or supracIavicuIar nodes. The deep Iymphatics begin in the fingers, continue along the digital vesseIs and course aIong the posterior interosseus and palmar arches up the forearm accompanying the large vesseIs, such as the uInar, radia1, anterior and posterior interossei. Each of these bIood vessels is accompanied by two lymph trunks which anastomose frequentIy. In the arm these vessels course aIong the brachia1 and radial arteries and terminate in the axillary lymph nodes, chieffy in the axillary vein group and the central group. Inflammation of the Iymphatics is usuaIIy caused by streptococcus, but many other organisms spread in this fashion. Clinically, Iymphangitis demonstrates a high temperature, tachycardia and malaise associated with red streaks aIong the course of the Iymphatic vesseIs. Abscesses may develop along the course of the Iymphatics in the intercaIated nodes. Treatment of Iymphangitis consists of immobiIization and chemotherapy. GENERAL

PRINCIPLES

OE TREATMENT

Treatment of hand infections must be carried out as early as possibte to prevent spread of infection and irreversibIe sequelae. The function of drains is to keep incisions open. They should never pIug the wound or prevent a free ffow of exudate. They should 442

SurgicaI never extend into tendon sheaths or joint spaces. VaseIine strips or small rubber strips are the usual drains used. In the fingers it is better to use smaI1 rubber strips by choice because of Iack of space. AI1 operations are carried out in a bIoodIess fieId with good Iighting and assistance under genera1 or regional anesthesia. Immobilization of the part is essential for recovery. This may be obtained by a massive dressing in the early stages of acute infection; this is Iater replaced by a pIaster of paris spIint. When the hand is immobilized for more than a day, it should be pIaced in the position of function, i.e., the wrist in 20 degrees dorsiffexion, the finger joints in slight ffexion, the thumb in abduction and opposition with its interphaIangeal joints sIightIy fIexed. Systemic diseases should be searched for in a11 cases, with particular emphasis on diabetes, Iues or the various bIeeding diatheses. The patient’s nutrition should be maintained in as norma a state as possibIe, with particuIar attention to correction of anemia, vitamin C

Review deficiency and Iow serum protein. AIthough many peopIe are being treated with cortisone today, one shouId remember that wounds and infections seem to hea more sIowIy when this is administered. The aftercare of each wound is designed to prevent saprophytic infection. Dkbridement of dead tissue shouId be performed whenever it occurs, and cIean granuIation tissue shouId be skin-grafted as soon as possibIe to prevent fibrosis. The subsequent changes of dressings shouId be carried out under aseptic conditions using steriIe instruments and surgical face masks. Physiotherapy in the form of active and passive motion shouId be instituted as soon as possibIe to prevent ankylosis of the finger joints. If a hand has been immobiIized for any length of time, physiotherapy shouId be directed to the eIbow and shouIders. In the oIder age group, these joints may become ankyIosed within a reIativeIy short period of time and the subsequent disability may outweigh the hand disabiIity.

II. TRAUMA The treatment of specific injuries to the hand wiI1 be discussed in the appropriate sections of this part but a few genera1 principIes concerning the care of the compound injured hand wiI1 be prefatoriIy presented. AI1 severe lacerations of the hand require care in the operating room. An adequate history and physical examination should be performed, so that any systemic disease may be discovered. The history is of great importance in ascertaining factors essentia1 to therapy, such as the causative agent, pIace of injury, circumstances under which it took pIace, type of first-aid treatment and the time from injury to hospita1 admission. A detaiIed examination of the hand and arm is begun before operation, with a steriIe dressing applied to the wound. This examination shouId incIude not onIy motion but aIso careful testing for sensation. The type of wound shouId also be noted since it is we11 known that incised wounds hea better than crushed or avulsed wounds. AI1 patients are treated under genera1 anesthesia or regiona anesthesia (brachia1 block). AI1 severe injuries are repaired in a bIoodless fieId obtained by appIication of a tourniquet to the upper arm. During the operation the

tourniquet shouId be released every hour to prevent ischemic changes in the nerves or other soft tissues of the arm. The surgeon puts on a cap and mask, scrubs his hands and dons a steriIe gown and gIoves. The injured hand is shaved from eIbow to fingertips and washed for twenty minutes with sapo moIIis. The surgeon changes gown and gIoves (if there is another surgeon on the case, he takes over) and the wound is irrigated with 5 or IO L. of sterile saline soIution, depending upon the degree of injury. FoIIowing this procedure the surgeon changes his gown and gIoves, and the wound is draped for operation. Dkbridement of the wound is done, with a11 dead and devitaIized tissue being removed. The detaiIed treatment of the various structures wiI1 be Iisted in subsequent sections of this part. Whether primary or deIayed suture is performed wiI1 depend on the type of injury, the cIeanIiness of the wound and the time interva1 between injury and treatment. A brief r&sum6 of the treatment of such wounds by the Boston City HospitaI Hand Service is as foIIows: Primary suture of cIean incised wounds is done within twenty-four 443

Hand Surgery hours when there is no inflammation. Primary suture of dirty incised wounds, clean avulsed and crushed wounds, and dirty avulsed and crushed wounds-if dbbridement is completecan be performed within tweIve hours if the wound shows no inflammation. When the

FIG. I I. Varicus suture technics for tendon repair. (a) BunnelI silk suture technic; (b) Mason-Allen silk suture technic; (c) stainIess steel wire pull-out technic (Bunnell).

dkbridement is incompIete in avuIsed and crushed wounds, deIayed closure of the wound should be performed. Using this system of treating wound injuries over a three-year period, postoperative sepsis developed in onIy five of 6 I 8 patients.25 When the wound has been cIosed, the hand is pIaced in a pIaster of paris cast in a position of function whenever this is possibIe. Tetanus antitoxin or tetanus toxoid is given. PeniciIIin has become routine for the first few postoperative days. The patient is hospitaIized for a11 serious injuries until one is sure that infection is not present in the wound. TENDONS

Tendon

Healing.

When lacerated tendon ends are approximated, there is an outpouring of fibrin, during the first two days foIIowing injury, which joins the tendon ends. By the fifth day there is an outgrowth of fibrobIasts from the connective tissue eIements of the tendon into this mass of fibrin. At the end of the 444

second week tendon fibers and cells begin to bridge the gap. During the third week there is formation of strong tendon coIIagen fibers. The edema and vascularity at the tendon juncture graduaIIy diminish, so that by the end of the fourth week there is good strength in the junction. There have been numerous studies during the past few years on the prevention of adhesions about tendons during recovery. Weckess et a1.26 found that film material such as human fibrin fiIm, bovine fibrin film and ceIIophane were effective in preventing adherence of the tendons. GonzaIez*’ found that the use of polyethylene tubes couId prevent adhesions around a tendon anastomosis. However, the tendon required approximateIy forty days for good healing, since the fiIm wrapped around the tendon interfered with the bIood suppIy at the tendon junction. This would Iimit the procedure for use in humans, since forty days’ immobiIization wouId stiffen the finger joints so that function wouId be greatly Iimited. Grantz8 studied the affect of cortisone on tendon healing and couId find no difference in the contro1 and cortisone-treated animaIs with regard to adhesion formation. A similar study was made by GonzaIezzg who could find no evidence that cortisone improved or interfered with the heaIing of wounds. Methods of Repair. The exact type of repair does not appear to affect the end result too much providing care is taken with the method Numerous methods are avaiIabIe using used. silk or puII-out wire sutures, according to the technics of BunneIIz3 or Mason and A1Ien.30 Figure I I demonstrates severa of these suture methods. In general, on the Hand Service at the Boston City HospitaI the BunneIl silk suture technic is used for tendon-to-tendon repair, and the wire puII-out technic for tendonto-bone repair. Other modifications of tendon repair have been devised. Jennings has recently used a barbed braided tantalum@ suture which is threaded through the proxima1 and distal tendons.31 A needIe is attached to both ends of the suture. The dista1 needIe is threaded through the tendon junction and brought out through the skin. Adequate tension is placed on this suture which is maintained by means of a button. The proxima1 portion of the suture is threaded through the skin loosely and appIied

Surgical over a button. A V-shaped stee1 prong applied in such a way that the prongs point toward the dista1 needIe holds the tendon in pIace. At the completion of heahng the suture is removed by cutting the dista1 wire and withdrawing the suture by means of the proximal wire simiIar to the puli-out technic of Bunnell. Those on the Hand Service at the Boston City Hospital have used this suture in a few cases but do not believe that it offers any particuIar advantage over more conventional methods of suture. The return of function is usually excehent in the extensor and flexor tendons when they are incised in the forearm, wrist or proxima1 paIm. With regard to the extensor tendons, many authors state that a simple hgure-ofeight suture i,s sufficient providing the wrist and digits are pIaced in dorsiflexion for three weeks. They state that the extensor tendons so interdigitate that splinting aIone often suffrces.23 In two cases of which the author has knowIedge the extensor tendons did not so interdigitate and the proxima1 ends retracted, pulling the suture Iine apart. It is beIieved that it is better to suture the extensor tendons as all other tendons are sutured. FIexor tendons repaired within the digita sheath or tunne1 have a poor prognosis. This “danger zone” is the area from the palmar crease to the middIe phalanx of each finger. In this narrow fibrous tunnel there are two cIoseIy adherent tendons sIiding over each other. Most attempts at repairing both these tendons resuIt in adhesion of the tendons to the tunne1 with marked limitation of motion of the finger. When the fIexor digitorum sublimis alone is divided, it is probabIy wiser to excise the dista1 portion to a few millimeters from its attachment to the middle phalanx and the proxima1 portion, so that it wiI1 retract to the palm. EarIy motion of the fingers shouId be instituted. The suture of one sIip of the subIimis tendon should likewise not be attempted. If both subIimis and profundus tendons are invoIved, the subIimis shouId be cut away as previously described and the profundus sutured. The annuIar ligament in the region of the tendon juncture should be excised compIeteIy as suggested by Mason.32 There is an increasing tendency on the part of surgeons to treat these injuries in the digital tunnels as primary skin wounds and do a delayed tendon grafting at a subsequent date. Some surgeons are even attempting a primary 44.5

Review tendon graft as initial treatment.33 This latter procedure should be viewed with caution, since if it fails and infection deveIops in the primary tendon graft it may be impossible to repair the finger. If the profundus tendon is severed at the Ievel of the middle phalanx, it may be advantageous to excise the distal portion and advance the proxima1 end into the distal phaIanx of the tinger. In this way there wiI1 be no suture Iine in the digital tunnel. If there is a contracture of the tendon, it may be stretched by dynamic SpIinting. Immobilization. Repaired tendons are immobilized in a pIaster of paris cast which is applied so that there is no tension on the tendon junction. The flexor tendons are immobilized for three weeks in a position of slight wrist ffexion with flexion of the invoIved fingers. The weak extensor tendons are immobilized for five weeks, usuaIIy with the wrist dorsiffexed about I 5 degrees, the metacarpophaIangea1 joints fuIIy extended with sIight hexion permissibIe in the proximal interphaIangea1 joints. If there has been loss of tendon, it may be necessary to flex or dorsihex the hand much more than this. As a ruIe, onIy injured digits shouId be immobiIized. In chiIdren and irresponsibIe patients the pIaster cast shouId be made suff~ciently strong in order to prevent breakage. A jtercare. When the cast and sutures are removed, physiotherapy should be started. Heat is of benefit, but the best physiotherapy is active and passive motion of the invoIved joints unti1 there is a maximum return of function. The wrist, elbow and shoulder of the involved extremity shouId be simiIarly treated. In partictdar, attention should be directed to the shouIder and motion should be begun as soon as possibIe even whiIe the plaster of paris cast is on the hand. Too often the hand injury recovers but the Iimitation of motion of the shoulder joint may be severeIy incapacitating. Ruptured Tendons. A sudden forced flexion of the dista1 interphaIangea1 joint wil1 produce an avuIsion of the extensor tendon from the dista1 phaIanx, producing a marked flexion deformity of the dista1 phaIanx. (Fig. 12.) This is known as baseball or maIIet finger. Conservative therapy is employed, with the dista1 interphaIangea1 joint immobiIized in a position of marked dorsifiexion for six to eight weeks. Although the dista1 joint is kept in dorsiflexion, the proximal interphaIangea1 joint shouId be

Hand Surgery kept in a position of 13 degrees flexion. This position is maintained by a plaster of paris cast. A Kirschner wire inserted through the distal, middIe and proximal phaIanges may be used to maintain the same position.34 If seen late after an injury, operation wiI1 probably be

that the most Iogical expIanation is that the mesotendon tears at the time of the original injury thus interfering with the blood supply of the tendon, resulting in an avascular necrosis. Operative findings supported his theory, for the tendon appeared swoIIen, yeIIowish and

FIG. IZ. BasebaIl or mallet finger. (a) Characteristic deformity; (b) rupture of extensor apparatus over distal interphalangeal joint.

necessary, suturing the dista1 phalanx technic. Buttonbole

the extensor tendon into and using a wire puII-out

Rupture

of tbe Extensor

Tendon.

The extensor communis insertion into the middIe phalanx may be torn from the middle phalanx permitting the IateraI bands of the extensor mechanism to slide IateraIIy over the interphaIangea1 joint, producing a characteristic deformity with the proximal interphaIangea1 joint being flexed and the dista1 interphaIangea1 joint extended. (Fig. 13.) Conservative therapy with immobiIization in a plaster cast may be successfu1, but usuaIIy such a finger wiI1 require operation for reinsertion of the communis tendon into the middle phaIanx. Rupture of tbe Extensor Pollicis Longus Tendon. This tendon is long and thin and slides

through a groove of the distal end of the radius beside Lister’s tubercIe. Any roughening of this groove due to an oId CoIIes fracture or to arthritis wiI1 cause an eventual rupture of the tendon. The characteristic position is the thumb held in flexion with an inabiIity to extend the dista1 interphaIangea1 joint. Trevo+ recently reported nine cases of this disease-a11 occurring in women-with the interva1 between fracture and tendon rupture varying from four weeks to one year. He raises the question as to whether or not the rupture is due to a roughening of the tendon by trauma. He thinks

FIG. 13. Buttonhole rupture of extensor tendon. (a) Characteristic deformity; (b) extensor tendon torn from middIe phalanx permitting IateraI bands to slide over proximaI interphaIangea1 joint.

bruised. The treament of this condition is surgical repair of the tendon whenever possibIe. Trevor did not find it necessary to approximate the ends, but occasionally a strong nyIon suture threaded criss-cross through the tendon and across the tendon gap suff%ed. A plaster cast is applied allowing a few degrees of flexion at the interphalangeal joint, and this is maintained for three weeks. An alternative procedure is suturing the extensor Iongus polIieis t&,don to that of the extensor indicis proprius. In cases in which none of these methods are possibIe, the method of FurIong36 in which a tenodesis between the dista1 ruptured tendon and the radius would give active extension of the termina1 thumb joint on flexion of the wrist joint. Rupture of Extensor Tendon. Various slips

Communis

Digitorum

of the extensor communis digitorum may rupture as they move across an irreguIarity in the radius due to an old fracture of the wrist. GIadstone3’ recently reported two such cases. Treatment of this is surgical repair of the invoIved tendon. James38 has recentIy reported pathoIogic ruptures where the tendons of the flexor

SurgicaI

Review tension on the suture line with the wrist and finger sIightIy ffexed. (Fig. 14.) If there is a great disparity in the tendon graft and the motor tendon, they may be sutured, as suggested by AIIen,3Y with the thin graft inserted through a stab wound in the proxima1 motor tendon and sutured with fine silk sutures.

poIlicis Iongus and the flexor profundus to the index fmger were completeIy divided and appeared to be due to a fraying from continued motion across a semilunar bone affected with Kienb8ck’s disease. Tendon Grafts. A tendon graft wiII be necessary when tendons are destroyed by trauma, burns or infection, or when a primary repair has been unsuccessfu1. The most frequent site for such a tendon graft is the “danger zone” of the fingers. Such grafts are performed within four to six weeks from the time of injury or disappearance of infection. If the soft tissue is not satisfactory over the tendon site, some skin-grafting procedure wiI1 be necessary to suppIy skin and subcutaneous tissue. Physiotherapy to improve joint motion is necessary, since joint function must be as cIose to norma as possible before a graft wi11 be successful. It is also essentia1 that the moving part have a good nerve supply. If the nerves are damaged, they should be repaired at the time of the grafting if possible. After the proper incisions are made in the hand to expose the diseased tendons, they are carefuIIy dissected from the scar tissue. Care is taken to see that the annuIar ligaments in the fingers are preserved to prevent bowing of the tendon graft. In the fingers the flexor digitorum sublimis and profundus are both removed from their insertion to the distal third of the palm. The source of the tendon graft is usuaIIy the palmaris Iongus tendon, when present, or the Iong extensor tendons of the toes. Some authors have suggested the use of the short extensor tendons of the toes because of their thinness. In the experience of the Boston City Hospital Hand Service, these usuaIly are not of sufficient length to permit an approximation of the tendon in the proxima1 third of the paIm, and for this reason their use is not justified. The donor tendon should be excised through IongitudinaI incisions, and as much paratenon as possible should be preserved. The graft is threaded through the preserved annular ligaments or through the bed of the tendon sheath. Using a wire pulI-out technic, the dista1 portion of the graft is inserted into the dista1 phaIanx either through a hole or a bone flap. The proxima1 portion of the tendon is sutured to the proximal profundus tendon in the proxima1 third of the paIm. The tension on the graft at the time of repair is an important factor. There shouId be just a slight amount of

FIG. 14. Tendon grafting. (a) The donor graft evtcnds from the distal phaIanx of the finger to ;Fc, proximal third of the paIm. (b) The distal end of the graft is inserted into the dista1 phalanx, and the proximal end is sutured to the profundus tendon in the proximal third of the paIm using a silk suture technic. The anastomosis fine is thus placrd outsidc the digital tunnel.

FIvnn40 notes that the tendon grafts mav be inserted into the distal DhaIanx Line: a DIain catgut puII-out suture &th the en& of the catgut being tied over a button on the dorsum of the dista1 DhaIanx. He uses catgut in this location, for ‘it is we11 known thuat catgut increases adhesion formation, and he believes that this is desirabIe at this Doint. If the tendon injury in;oIves the flexor profundus tendon dista1 to the proximal interphaIangea1 joint with norma flexor digitorum Y

447

_I

Hand

Surgery sheaths over the radia1 styloid under which the tendons of the abductor Iongus pollicis and extensor poIIicis brevis glide. Lapidus and Fenton 42have recentIy reviewed 369 cases in which 420 tendon sheaths were invoIved. The sheaths of the abductor Iongus poIIicis and extensor poIIicis brevis made up 39 per cent of a11cases; the flexor poIIicis Iongus, 31.9 per cent; the flexor sheath of the third finger, IO per cent; the flexor sheath of the fourth finger, 10.9 per cent with occasiona invoIvement of the flexor sheath of the index finger, fifth finger and other extensor tendons of the wrist. Burman43 has reported a group of cases of this disease which were confmed to extensor tendons of the wrist other than the abductor poIIicis Iongus and the extensor poIIicis brevis. In every case reported by Lapidus some occupationa1 motion was present which seemed to account for the Iocation of the disease. He found that the condition was more prone to deveIop in “a new worker unaccustomed to the job, in an oId worker out of training and returning to his task after a period of idIeness, or in a worker who is asked to speed up his output to meet a new production quota.“42 As further evidence that trauma may produce this condition, Enge144 reported three cases which appeared to be produced by exposure to high temperature. It is obvious that a11 such cases are not occupational, since Sprecher45 has recentIy reported a series of twelve cases appearing in patients before the age of three. When the disease occurs in the fibrous sheaths of the fingers (trigger finger), there is at first diffrcuIty in movement of the fingers associated with pain on ffexion. As the disease progresses, a snapping may be feIt and heard as the finger is extended and flexed. If the disease is aIIowed to continue, it may become Iocked in Aexion or extension. Associated with this there wiI1 be tenderness over the metacarpa head of the involved finger at the site of the disease process, and a buIbous enlargement of the tendon may be feIt in the same Iocation. Treatment is incision of the constricted area of the tendon sheath. Stenosing tendovaginitis of the tendon sheaths of the abductor poIIicis Iongus and the extensor poIIicis brevis was first recognized by de Quervain in 1895. Since that time many articles have been written about this subject. This occurs much more frequently in women.

sublimis function, a grafting procedure is probabIy not indicated but some form of arthrodesis with the distal joint at 20 degrees Aexion should be petformed. When the flexor poIIicis Iongus tendon has to be repIaced, tendon grafting may be done. The procedure of transferring the flexor digitorum subIimis of the ring finger to replace the fIexor poIIicis Iongus tendon in the thumb may be folIowed. Tendon grafts for extensor tendon injuries are not indicated as frequentIy as flexor injuries. When necessary, the Iong extensor tendons of the third and fourth toes can be used as donor grafts, or a transfer of the extensor indicis proprius or extensor digiti quinti may be usefu1. The correct position of the hand folIowing extensor tendon grafting is 3 to 13 degrees dorsiffexion of the wrist with about 3 degrees ffexion in the metacarpophaIangeaI joints. FoIIowing tendon grafting the hands are kept in the proper position by a pIaster cast for three to four weeks, folIowing which the cast and sutures are removed and physiotherapy instituted. The patient’s menta1 drive and iniative are of profound importance in the recovery of function in tendon grafts. Boyes41 has recentIy anaIyzed 138 tendon grafts with flexor tendon damage in the “critica1” zone. When there was no joint damage or scarring, he obtained good resuIts. In a11 cases the fingers could be flexed within 145 inches of the paIm; in go per cent of the cases, within I inch; in 35 per cent, 45 inch; in IO per cent, compIete ffexion to the proximal digital crease. When there was joint damage, scarring or muItipIe damage of the fingers, however, the resuIts were not as good. The author obtained best resuIts with stainIess wire sutures which were used at the insertion in the phalanx and aIso as the suture in the palm together with deIiberate excision of al1 remaining sheath tissue. The best donor tendon was the paImaris Iongus with its entire paratenon. Stenosing Tendovaginitis. This is an infIammatory condition of the tendon sheath in which the sheath becomes constricted and the underIying tendon becomes inflamed, deveIoping adhesions with subsequent limitation of function of the tendon. It appears wherever a tendon glides under a fibrous tunne1 such as the annuIar Iigaments over the metacarpa1 heads of the fingers and thumb, and the fibrous 448

Surgical In Lapidus’ series, 75 per cent of 369 patients were femaIe.42 The disease is manifested by pain and tenderness over the stytoid process of the radius. Motion of the thumb produces pain particularly on flexion. When the thumb is held fIexed within the fist and the hand ulnar deviated, there is marked pain at the involved site.46 There may be swelling over the involved tendons and occasionally erythema is present. Snapping or locking is never seen in this disease. Treatment may be conservative with immobilization in a plaster of pari; cast. Surgical treathowever, is simple and successful. ment, Through a smal1, transverse incision over the abductor pollicis Iongus tendon, the involved tendon sheath is incised IongitudinaIIy throughout the entire distance of the constriction. The presence of accessory tendons in the tendon sheath of the abductor pollicis Iongus is common. It is not necessary to excise these for relief of symptoms. FolIowing surgery a pressure dressing is applied and active motion is begun shortIy after operation. Cohen4’ reported severa cases in which recurrence of the disease followed surgery. On reoperation it was found that the tendon of the extensor pollicis brevis passed through a separate fibrous cana which was surrounded by a typicahy thickened synovial sheath, the resection of which gave relief of symptoms. Murphy48 simiIarIy reported two cases of Quervain’s disease in which the constriction involved onIy the extensor pohicis brevis which was in a separate compartment from the abductor pollicis Iongus. Howard, BunnelI and Pratt4g have recently reported on the treatment of Quervain’s disease with hydrocortone. SeveraI cubic centimeters of this were injected into the invoIved tendon sheath, with relief of symptoms. Traumatic Tendinitis. OccasionaIIy because of a tendon of prolonged use, inhammation may occur which may persist for weeks or months. It is most frequently seen in the tendons near the insertions of the extensor carpi radialis Iongus, in which case there wit1 be tenderness over the involved tendon and crepitation can be felt on flexing and extending the wrist. Burman60 has reported on several cases of tendinitis at the insertion of the common extensor tendons of the fingers. One of these fingers was expIored, and friabIe granuIationlike tissue was found beneath the tendon. 449

Review HistoIogic section showed vascuiarized fibrotic tissue. Seidensteinsl has reported numerous cases of a similar disease occurring along the course of the flexor carpi ulnaris at or near the piaiform bone and along the course of the flexor carpi radialis at or about the greater multanguIar. Associated with the tenderness and pain in these areas, x-rays demonstrated calcific deposits in the peritendinous soft tissues. Phalens* has simiIarly reported on calcium deposits around the tendon of the flexor carpi ulnaris associated with pain and tenderness over the invoIved area. The disease process is self-limited and usuaIIy responds to immobilization in a plaster of paris cast. NERVE

INJURIES

Healing of Nerve. When a nerve is injured, there are severa microscopic and macroscopic changes which occur. The distal portion of nerve undergoes wallerian degeneration in which the axis cylinder disintegrates, the meduIlary sheath fragments, and the sheath of Schwann ceIIs degenerate. Similar changes occur in the proximat nerve up to the first node of Ranvier. The cellular changes in the celI nucIeus in the spina cord occur during this same period. The axis cylinders begin to proliferate and emerge from the cut proximal nerve end where they become emeshed with an overgrowth of connective tissue from the perineurium, endoneurium, epineurium and sheath of Schwann. A recognized nodule thus appears at the end of the proxima1 nerve which has been called an “amputation neuroma.” At the distal end of the nerve there may be some slight tendency for the connective tissue to grow and form a “distaI glioma.” If the freshIy incised nerve is sutured or if in an old injury the scarred portions are cut away and the ends approximated, normal nerve healing may occur. The neurohbrobIasts proIiferate and bridge the gap between the nerve ends and will accompany and ensheath the regenerating nerve fibers down the distaI nerve.53 The Schwann cehs pIay onIy a smalI part in the regeneration of nerve. The nerve fibriIs continue to grow down the distaI nerve essentiahy in the meshes between the ceils of the degenerating distaI nerve.53 The first cIinica1 manifestation of regenerating nerve fibriIs down a nerve are the occurrence of paresthesias along the nerve on per-

Hand cussion. If the nerve is percussed, beginning distally and proceeding proximaIIy, a point wiII be reached at which the patient feeIs a “tingling or buzzing ” sensation with radiation of sensation down to the invoIved hand area. The advancing edge of this sensitive area in the nerve shouId be measured at intervals, using some bony prominence as a guide. This is known as TineI’s sign and is a rough test of nerve recovery, since one can never be sure that the nerve fibriIs producing the paresthesias will function cIinicaIIy. The cIinica1 manifestations of nerve recovery are return of sympathetic tone, sensation and motor function. Various electrica technics have been used for testing of nerve recovery, such as eIectrodiagnosis and eIectromyography.54 These are of great prognostic vaIue since they may save many months of futile waiting for cIinica1 manifestations in cases in which reoperation on a nerve or a tendon transfer is being contempIated. Nerve Injury Patterns. Ulnar nerve: The area of sensory Ioss with uInar nerve paIsy consists of the voIar and dorsa1 aspects of the paIm and fingers on the uInar side of the hand from a line bisecting the ring finger. If the injury occurs above the eIbow, the fIexor carpi uInaris and flexor digitorum profundus to the fourth and fifth fingers are paraIyzed. The intrinsic muscIes of the hand innervated by the uInar nerve are the abductor digiti quinti, Aexor digiti quinti, opponens digiti quinti, the dorsa1 and voIar interossei, the adductor poIIicis, the deep head of the flexor poIIicis brevis, and the IumbricaI muscles to the fourth and fifth fingers. The interossei can be tested by abducting and adducting the fingers with the metacarpophaIangea1 joints heId extended. It is we11 to remember that faIse abduction and adduction can occur through flexion and extension of the fingers. The abductor digiti quinti and the first dorsa1 interosseus are convenient musc1e.s for testing, since the atrophy of these muscIes is quite apparent in an injured hand. The adductor poIIicis may be tested by requesting the patient to grasp a newspaper with both hands, puIIing the hands away from each other without reIeasing the grip. When the adductor poIIicis is paraIyzed, the thumb is ffexed at the interphaIangea1 joint because of contraction of the flexor poIIicis Iongus (Froment’s sign). If the palsy continues, trophic changes wiI1 take place in the fifth finger so that it wiI1 appear tapered, and nai1 and hair

Surgery growth will change. The characteristic deformity of this injury is flexion of the fourth and fifth fingers with the thumb heId in sIight abduction. The flexion contracture of the fourth and fifth fingers is worse if the injurv is below the innervation of the flexor dig;torum profundus. It is we11 to remember that anomaIous innervation of the intrinsic muscIes of the hand may take pIace. In an exceIIe& study of this subject by Rowntree,55 the previousIy mentioned socaIIed norma innervation of the intrinsic muscIes was present in 0nIy 15.5 per cent of 226 cases. In 32 per cent of the cases the flexor brevis pollicis was soIeIy suppIied by the uInar nerve; in 33 per cent both heads were suppIied compIeteIy by the median nerve. Other outstanding anomalies were as follows: AI1 the thenar muscles were supplied by the uInar nerve in 2 per cent of cases; a11 the thenar and the adductor poIIicis muscIes were suppIied by the median nerve in 2 per cent of cases; a11 the thenar muscIes, incIuding the adductor poIIicis and the first dorsa1 interosseus, were suppIied by the median nerve in I per cent of cases. In a study of periphera1 nerve injuries during World War II Murphey et aI. found anomaIous innervation in some of the intrinsic muscles of the hand. In four cases of 698 uInar nerve injuries, the first dorsa1 interosseus was found to be innervated by the median nerve, either by a branch given from the median nerve to the uInar nerve in the forearm or by way of a branch directIy to the first dorsal interosseus muscIes in the hand. In two cases the ffexor poIIicis brevis had an anomaIous innervation; in one case the abductor minimi digiti was suppIied by the median nerve; in another case the opponens poIIicis was suppIied by the uInar nerve. Prognosis foIlowing repair of uInar nerve injuries is exceIIent as far as return of sensation and motor function in the Iarge forearm muscles are concerned. However, the intrinsic muscIes of the hand are so smaI1 that they usuaIIy atrophy before they are renervated. Cases of ulnar nerve injury with the best prognosis as far as intrinsic motor function is concerned are those in and about the wrist in the younger age group. Median nerve: The sensory Ioss in median nerve paIsy consists of anesthesia on the volar aspect of the paIm and fingers Iateral to a Iine bisecting the ring finger. The dorsum of the dista1 phaIanx of the thumb, index, middIe and

Surgical

Review ing repair of the radiaI nerve is exceIIent, since most of the muscIe bellies supplied by this nerve are Iarge. During World War II numerous repairs were attempted of the deep branch of the radial nerve with considerable success. Mayer and MayfieId6g studied fifty-eight cases, in which end-to-end suture was possible in thirty-nine. A folIow-up study of twenty-six of the patients who were seen more than six months after surgery reveaIed that 84 per cent showed partiaI or ful1 recovery folIowing the procedure. Nerve ends are approxiMethods of Repair. mated using No. oooooo silk sutures which pass through the epineurium of the nerve. The suture should not be allowed to extend into the nerve for fear of damage to nerve fibriIs with subsequent poor recovery. In oId injuries the amputation neuroma shouId be excised back to normal nerve fibrils, and the distal end should be freshened to reIativeIy normaI tissue. The nerve approximation is done simiIarIy to a fresh injury. Since it is a primary requisite to suture the nerve without tension, there are severa ways by which this can be done. SimpIe neurolysis of the invoIved nerve over a considerable portion of its normal bed wiI1 often serve the purpose. Joints may be flexed on either side of the nerve repair in order to gain distance. In the case of the uInar nerve, it may be taken from its normal bed behind the medial epicondyle and transpIanted anteriorly, taking care not to damage the nerve fibers going to the fIexor carpi uInaris and flexor digitorum profundus. An excelIent account of the technic for transplanting the uInar nerve has been presented by Learmonth.6o The radia1 nerve may be translocated anterior to the humerus in order to achieve a similar purpose. In rare instances with extensive loss of nerve tissue it has been necessary to shorten bone Iength in order to anastomose nerves.61 FolIowing operation the invoIved Aftercare. extremity shouId be immobilized in a plaster of paris cast in a position consistent with the least tension on the suture Iine for a period of three weeks. After removat of the cast and sutures, subsequent care is devoted to physiotherapy to maintain joint function of a11 the joints in the involved extremity and adequate splinting to prevent overstretching of paraIyzed muscIes. For radial nerve injuries a cockup type of splint, preferabIy a dynamic one, is

radial haIf of the dista1 phalanx of the fourth finger are similarly involved. The median nerve supplies the foIlowing muscles of the forearm: pronator teres, Aexor carpi radiaIis, palmaris Iongus, flexor digitorum subIimis, fIexor digitorum profundus to the second and third fingers, flexor pollicis Iongus and pronator quadratus. The intrinsic muscIes in the hand suppIied by the median nerve are the abductor polIicis brevis, the opponens pollicis and the superficial head of the fIexor pollicis brevis. The possibility of anomalous innervation as mentioned in the previous section must be considered in certain cases. Trophic changes deveIop in the thumb, index and middIe fingers consisting of loss of soft tissues, tapering of the fingers, stiffening of the joints and changes in the hair and nail growth. The characteristic deformity is Ioss of substance of the thenar muscIe group together with an adduction contracture of the thumb. The prognosis following repair of the median nerve is excellent for sensation and Iarge muscle function. The intrinsic muscIes of the thenar eminence, however, rarely recover unless the nerve injury is in the region of the wrist in the younger age group. Causalgia, which occurs in about 5 per cent of peripheral nerve injuries, is most commonIy seen after median nerve injuries.57 Combined

median

and

ulnar

nerve

palsies:

The characteristic deformity of this condition is ffexion of the interphaIangea1 joints of the fingers with extension or hyperextension of the metacarpophaIangea1 joints. This is a so-called “ctawhand,” or as described by BunnelI,68 “the intrinsic minus position.” Radial nerve: The sensory loss in radiaI nerve palsy is on the dorsolateral surface of the hand. In the forearm it suppIies the foIIowing muscIes: brachioradiaIis, extensor carpi radialis Iongus, extensor carpi radialis brevis, extensor carpi utnaris, extensor communis digitorum. The deep branch of the radiaI nerve supplies the supinator muscIe, extensor indicis proprius, extensor pollicis Iongus, extensor polIicis brevis and abductor poIIicis Iongus. The obvious deformity with the compIete radiaI nerve paIsy is the wrist, finger and thumb drop. When the deep branch of the radiaI nerve is severed, there is a characteristic inability to extend the thumb which often may be overIooked. In particular, it should be watched for in fractures of the head of the radius. The prognosis folIow457

Hand

Surgery

valuable. For median nerves a splint to restore opposition to the thumb and to maintain the web space between the thumb and index finger should be utiIized. The usual ulnar nerve paralysis requires no particular splinting. With the combined median and ulnar nerve palsies,

transfer is due to the tenodesis whereby flexion of the wrist produces extension of the fingers. Restoration of opposition and abduction of the thumb folIowing nerve injury is of primary importance. The principles outlined by BunneIP4 in this regard are still of paramount

FIG. 14. Tendon transfer for opponens palsy. The flexor digitorum subtimis tendon to the ring finger is rerouted through the wrist, Iooped around the flexor carpi uInaris muscIe as a puIIey and brought subcutaneously to the proximal phalanx of the thumb according to the principIe of Bunnell.

however, some form of “knuckle duster” is indicated which wiII keep the metacarpophalangeal joints in a position of about 20 degrees flexion together with an opponens splint. Tendon Transfer. When recovery of motor function does not occur following nerve suture, various tendon transplants may be done to restore function. In nerve injuries where motor return is not expected for twelve to eighteen months there is an increasing tendency to perform the tendon transfers early, using them as a type of dynamic splinting. The wrist, finger and thumb drop of radial palsy may be successfully treated by some modification of the Jones tendon transfer.62 An excehent presentation of this subject was recently written by Scuderi63 who described his experiences in World War II. He believed that the best resuhs were obtained by transferring the flexor carpi ulnaris into the extensor tendons of the second, third, fourth and fifth fingers; and the palmaris Iongus into the severed extensor pollicis Iongus tendon. If the palmaris Iongus tendon is absent, the IIexor carpi radialis should be inserted into one of the thumb tendons. Whenever possible it is well to keep one of the flexors of the wrist joint intact, for if all three are used for the transfer there is a great weakness of wrist flexion. The author has seen one case in which the wrist became fixed in extension because of this. It is well to maintain active wrist flexion, since in many cases the beneficial results obtained from this tendon

importance. He stated that the tendon from its insertion in the thumb should pass subcutaneously in the direction of the pisiform bone; the insertion of the tendon should be on the dorsal ulnar aspect of the base of the proximal phalanx of the thumb and should pass directly over the summit of the metacarpophalangeal joint, not distal to it. Various combinations of pulleys, tendons and motors have been used for this operation, using the foregoing principles. One of the most common variants of this operation is the one in which the flexor digitorum sublimis to the ring linger is removed from its attachment in the middle phalanx, pulled out through the wrist, Iooped around the flexor carpi ulnaris and brought subcutaneously through a tunnel to be inserted into the proximal phalanx of the thumb. (Fig. IT.) A review of seventy-five cases in which various modifications of the Bunnell procedure were utilized was presented by Kirklin and Thomas.65 Goldner and ErwirP have analyzed various procedures of value for paralysis of the thumb. If some of the extrinsic strength of the thumb is missing, it must be restored before the opponens operation is done. For instance, if the extensor poIIicis Iongus is weak, the extensor carpi radialis Iongus can be sutured to it. If the flexor pollicis is weak, the flexor digitorum sublimis to the index or middle linger can be sutured into the tendon at the wrist. If there is a severe adduction contracture of the thumb, it will have to be overcome by 452

Surgical

Review

various procedures such as capsulotomy of the metacarpophalangeal joint of the thumb, cutting of the fascia between the first and second metacarpals, stripping the first dorsal interosseus from the first metacarpa1 bone, division of a contracted adductor polIicis muscle at its point of insertion and capsuIotomy of the carpometacarpa1 joint. After the thumb is mobitized in a pIaster cast for three weeks, a sublimis transpIant can be done to restore opposition. Thompson67 has described another operation for opponens paraIysis in which the flexor digitorum sublimis tendon is removed through an incision in the palm after sectioning it at the base of the ring finger. Another incision is made on the dorsa1 surface of the proxima1 phalanx of the thumb, and the flexor sublimis tendon is brought through a subcutaneous tunne1 across the thenar eminence. The tendon is spIit IongitudinaIIy, and one end is inserted into the dista1 end of the metacarpa1 of the thumb and the other into the proxima1 phaIanx. It does not seem that this operation restores abduction of the thumb as we11 as the BunneII procedure. Kirklin and ThomasG5 mention an exceIIent point about using the Thompson operation whenever there is scarring over the dista1 haIf of the forearm which would prevent a tendon transfer in this area. Whenever it is impossibIe to do a tendon transfer to restore opposition of the thumb, a bone procedure may be necessary such as a metacarpa1 osteotomy or a bone wedge between the first and second metacarpa1. It wouId seem that for a bone bIock to be successfu1 one shouId have good ffexion of the fingers together with strong abduction of the index finger. BrooksGs has recentIy reviewed sixteen cases of intermetacarpa1 bone grafts for thenar paralysis, and there were onIy two compIete faiIures in the entire group. It is interesting that five grafts faiIed to fuse at one end and it did not seem to affect function very much. As a matter of fact, in one patient pseudoarthrosis deveIoped which seemed to heIp the function of the thumb. He mentioned that if one was in doubt about the benefit which couId be derived from such an operation, a tria1 pIaster fixation of the thumb in the position of function might be indicated. SmiIIiesg uses a Kirschner wire which transfixes the bone bIock Iengthwise as we11 as impaIing the metacarpats, thus fixing 443

this fusion without the use of a pIaster of paris cast. This pin is Ieft in the bone for eight weeks. ParaIysis of the interosseus and IumbricaI muscIes resuIts in the “clawhand or intrinsic minus hand.” There is a ffexion contracture of the interphaIangea1 joints, and the metacarpophaIangea1 joints are heId in extension or hyperextension. Extension of the middIe and distal phalanges of the fingers can be performed by the extensor communis tendon through its action on the IateraI bands if the proxima1 phalanges are heId in slight ffexion or if the wrist is flexed. On the other hand, when these metacarpophalangeal joints and even the wrist are held in extension, the extensor tendons have IittIe affect on extension of the dista1 phaIanges. If contraction of the metacarpophaIangea1 joint takes pIace so that hyperextension is impossible, the cIaw deformity is Iess obvious. This is aIso true if the nerve Iesions responsibIe for the claw deformity are high enough to paraIyze the flexors of the fingers. For most cases of clawhand, the Bunnell procedure has proven of great benefit. In this operation the flexor digitorum sublimis tendons are removed from their insertions in the middIe phaIanx, withdrawn from the paIm, spIit and passed through the IumbricaI canaIs to be attached to the transverse fibers and IateraI bands of the fingers. The split strands from each tendon shouId go either to the radial or uInar side of the fingers, so that Iateral motion of the fingers wiI1 be possibIe. Each finger should have at Ieast one tendon attached to it, so that the dista1 two joints can extend and the metacarpophalangeal joint ffex.23 If sufficient tendons are not avaiIabIe, the extensor proprius tendon of the index finger can be utiIized to restore abduction to the index finger as we11 as extension of the distal joints. The hands and fingers are spIinted for three weeks with the wrist in ffexion. On the fourth week Iight motion may be begun, with physiotherapy folIowing this. Brand’O has modified this operation sIightIy in restoring function to hands paralyzed by Ieprosy. An incision is made on one side of the finger only, and the tendon transpIants are inserted to the radia1 side of each finger. He uses the index finger tendon for the radia1 side of the index finger. The Iong finger tendon is spIit and one-haIf is used for the Iong finger and one-half for the ring finger. The fifth finger tendon is used onIy for the fifth finger, thus

Hand

Surgery carpi uInaris is split from one-third the distance above its insertion and Ieft attached to the metacarpals. Each of these strands is split in two, and they are routed through the interosseus space to the radiaI side of each finger anterior to the transverse metacarpal ligament.

saving the ring finger sublimis for use in restoring opposition to the thumb. As each tendon is brought through the Iumbrical canal, a slit is made in the Iumbrical tendon. The transferred tendon is passed through this aperture and sutured to the dorsa1 edge of the extensor

FIG. 16. The Bunnell procedure for paralysis of interosseus and Iumbrical muscIes. Slip of flexor digitorum subtimis is removed from finger and passed through Iumbrical cana to insert into IateraI bands. FIG. 17. Fowler procedure for paraIysis of interosseus and Iumbrical mu&es. Slip of extensor indicis proprius is threaded between metacarpals and carried anterior to transverse metacarpal ligament and inserted into IateraI bands of extensor apparatus.

The hand is mobilized in a pressure dressing with the wrist in dorsiflexion, the metacarpophaIangea1 joints in ffexion and the distal phaIanges in extension for three weeks. FoIlowing this the cast is removed and active motion begun. This operation wouId appear to be most successfu1 when there is marked hyperextension of the metacarpophaIangea1 joint. Figure 16 demonstrates the principles invoIved in the BunneII procedure for interosseus and Iumbrical muscIe atrophy. Figure 17 demonstrates the principles involved in the Fowler In cases in which none of these procedure. procedures are practica1 some form of arthrodesis of the finger joints wiI1 be necessary. Compression Palsy. The median nerve may be compressed in the carpal tunnel, producing a typica median palsy in the hand. There is usuaIIy pain over the median nerve distribution. As the disease progresses, there will be a

expansion just proxima1 to the interphatangeal joint. Riordan has recentIy reported on the use of a tenodesis operation in simiIar cases based on the so-called FowIer principIe, i.e., if the metacarpophaIangea1 joint is stabiIized in a position of slight ffexion the extensor communis tendon wilI be able to extend the dista1 joints. He used the Fowler procedure in which the extensor indicis proprius and the extensor digiti quinti proprius are split, each into two strands, and each slip is then passed through the interosseus space anterior to the transverse metacarpa1 and inserted into the extensor ligament Each sIip is inserted into the aponeurosis. radial side of each phalanx. In cases in which there is not sufficient strength in the extensor muscIes Riordan” has devised his own procedure in which one-haIf of the extensor carpi radialis and extensor 454

Surgical

Review four presented bony irregutarities in the uInar disgroove; three were caused by recurrent location of the uInar nerve; two were due to congenital vaIgus deformity with an anterior disIocation at the head of the radius; three were due to an oId soft tissue injury at the site of the ulnar nerve with subsequent compression by scar tissue. Three of the cases presented no mechanica abnormaIity of the elbow joint. The occupation of two of these patients required much hammering. Another case was that of a student who had the habit of sitting for many hours with his head on the Ieft hand and the elbow pressing against the tabIe. Treatment of this condition consists of transIocation of the ulnar nerve anterior to the epicondyIe. A good account of this operation has been previously mentioned.60 As with tardy median nerve palsy, it is essential to operate before there is definite wasting of the intrinsic muscIes. This is we11 emphasized in McGowan’s report in which a11 the cases improved as far as sensation was concerned, but when there was wasting of the interosseus muscle with no voluntary power there was little motor improvement. Brooks75 has recentIy reported a series of cases involving nerve compression by ganglia. Four cases were ganglia near the elbow causing compression of the ulnar nerve. The ganglia were attached to the capsuIe of the elbow joint and compressed the nerve. There were four cases of ganglia at the wrist, two causing an ulnar nerve compression and two producing a median nerve compression. The radial nerve may be compressed in the heaIing of a fractured humerus resulting in late radial nerve palsy which may require operation on the fracture site with neuroIysis of the nerve.

definite pattern of hypesthesia or anesthesia over the median nerve distribution and opposition of the thumb may disappear. Percussion of the median nerve at the Aexion crease of the wrist wiI1 produce paresthesias along the median nerve.72 The cause of this condition is varied. OccasionaIIy some disturbance in the carpa canal such as a fracture or dislocation might so narrow the tunnel as to produce the syndrome. Acute compression by hemorrhage has occasionally been the cause. However, in most cases it appears to be due to occupationa strain. In extension of the wrist the pressure in the carpal tunne1 is three times greater than when the wrist is fIexed.73 Also when the wrist is flexed, the edge of the transverse carpa Iigament can pinch the median nerve. It is obvious that any action involving extension and llexion of the wrist couId conceivabIy lead to this condition. The author has recentIy seen a case in an elevator operator in which, at the time of operation, the flexor tendons appeared slightly hyperemic and thickened as if they were the site of a chronic tendinitis. Their increased bulk may have helped produce the compression palsy. Treatment of this condition is reIativeIy simpIe and invoIves incision of the transverse carpal Iigament which is exposed through an S-shaped incision across the wrist. The ligament shouId be sectioned aIong its medial border to minimize the possibility of damage to the motor branch of the median nerve. It is essentiat that the diagnosis in this case be made before opponens palsy occurs, since this may never return. Reports of tardy ulnar palsy are increasing in the surgica1 literature. It is usually seen as a complication of a fracture of the IateraI humera condyle resulting in valgus deformity of the eIbow. If the elbow is flexed, the nerve becomes stretched and may even sIip over the edge of the condyle. There is usuaIIy paresthesia and hypesthesia over the ulnar nerve distribution folIowed by increasing weakness of the intrinsic muscles. A Tine1 sign wil1 be eIicited over the ulnar nerve in the condyIar tunnel, and a tender enlargement of the nerve may be found in this area. McGowan74 has presented a series of fortysix cases of this disease. In this series twentyone cases were due to an oId fracture; four were due to osteoarthritis with.no history of fracture;

AMPUTATIONS

AND

SEVERE

LACERATIONS

In digit amputations, especiaIIy of the thumb and index finger, every effort should be made to maintain the length of the finger. If bone is not exposed at the tip, the wound may be covered with a spIit-thickness skin graft. If bone is exposed, either a full-thickness skin grait or a smaI1 ffap raised from the thenar eminence shouId be performed. With the fuIIthickness graft it is often difEcuIt to obtain pressure on the tip of the finger. This may be accomplished by Ieaving the sk.in graft sutures Iong and tying them over a piece of foam rubber. (Fig. 18.) 455

Hand Surgery Kutler7” has described a procedure for fingertip amputation in which a V-shaped flap is incised on either side of the finger but left attached to the underIying subcutaneous tissue. These flaps are brought together in the midline and the resuItant IateraI defect closed by the usua1 V-Y procedure.

skin grafting for hand lvritten by Dubitoir.77

coverage

has

been

BURNS

EarIy treatment of the burned hand consists of minima1 debridement and a firm pressure dressing. The hand should be immobiIized in a position of function, care being taken that the gauze dressing extends between the fingers to prevent their adherence to each other. The fingers should be spread apart with a11 the joints pIaced in ffexion, and the thumb brought into a position of opposition and abduction. The tips of the fingers shouId be exposed so that the state of circuIation in the hand can be observed. After severa days the dressing may be changed daiIy and the hand soaked in peroxide or haIf-strength Dakin solutions. Clean granulating areas shouId be skin grafted as soon as possibIe with spIit-thickness skin grafts of approximateIy 13(000 inch in thickness. As soon as possible after the grafting procedures, motion shouId be started in the fingers. Subsequent keIoids or thin constricting scar areas shouId be excised and skin grafted with a spIit-thickness skin graft. Burns on the dorsum of the hand are more frequent than others and much has been written concerning them.78-80 When the burn does not invoIve the underlying tendons, the granulating burn area or thin atrophic scar area shouId be excised compIeteIy in a bIoodIess field, taking care to avoid the underIying dorsal veins and nerves. Excision shouId be so pIanned that the resuItant scar will not cross a flexion crease at the wrist or finger joints. A split-thickness skin graft is obtained and taiIored to fit the defect and sutured in pIace. The web space of the fingers demand attention, since often adduction contractures may take place in this area. The skin graft should completely cover the web space down to the voIar surface, taking care that the digita nerves in this area are not damaged. When the burns are deep and underIying tendons or bones are destroyed, a spIitthickness graft is not adequate and a pedicle ffap of skin and subcutaneous tissue must be used foIlowed by subsequent reconstructive procedures. Even when the dorsum has been properIy skin grafted, contractures of joints and connective tissue in the hand may remain which must be corrected by proper dynamic splinting and physiotherapy. Burns on the volar surface of the paIm of the

FIG. 18. Method of applying pressure to fingertip skin grafts. (a) Skin graft sutures are left Iong. (h) They are tied over a piece of foam rubber. Since fingertip injuries may be painfu1 because of underIying amputation neuromas, a carefu1 search shouId be made for the digita nerve at the time of each amputation. SufXcient nerve shouId then be excised so that it will retract from the fingertip. It must be remembered that grafting of fingertips prolongs the heaIing time of the injury. In many cases in which the patient is eIderIy, shortening of the finger by pIastic amputation, Ieaving the scar on the dorsum of the finger with a Iong voIar flap, may give quicker wound heaIing. When an entire finger needs amputating, one can occasionally cIose the defect in an adjacent portion of the hand by fleting the finger and covering the defect with the saIvaged skin. Defects on the volar surface *of fingers, where tendons are exposed, can be cIosed by swinging a skin ffap from the IateraI side of the finger and covering the IateraI defect with a spIit-thickness skin graft. On other areas of the hand various combinations of spIit-thickness skin grafting pIus shifting of skin flaps wiI1 be necessary to cover serious wounds. It is essential that the wound be covered compIeteIy to prevent subsequent scar tissue formation in the hand. A review of 456

Surgical

Review bowing, it may be necessary to use traction. This may be accomplished by means of a coat hanger which is incorporated in a pIaster gauntlet. (Fig. 19.) To prevent the finger from s&pping between the wire struts, adhesive tape or pIaster of paris slabs are used. Pulp traction

hand may be treated with spIit-thickness skin grafts if the underIying tendon sheaths are preserved. If they are destroyed, a pedicIe ffap wiIl be necessary to permit subsequent reconstructive procedures. Burns on the fingers may usualIy be adequately covered with spIit-thickness skin grafts. As a ruIe, if the burn is so severe as to destroy underIying tendons or joints, reconstructive procedures in the fingers are impossibIe. The foregoing methods of burn treatment often resuIt in much fibrosis due to the skin grafting of granulation tissue. There is an increasing tendency to excise these burns at the time of injury with immediate split-thickness skin grafting. BONES

A few genera1 principIes shouId be emphasized: Finger fractures shouId be immobilized in a position of 13 degrees fIexion at each joint. Only the injured finger should be immobiIized to prevent Iimitation of motion in other fingers. Watson-Jonessl suggests that even this is not enough, but that every effort shouId be made to exercise actively the uninjured fingers through the compIete range of motion. Immobilization is seIdom necessary beyond three weeks. Beware of limitation of motion of the shoulder and insist on putting the shoulder through a fuI1 range of motion every day! Fractures of the Distal Phalanx. These fractures are often associated with a subungua1 hematoma which may have to be evacuated to prevent pain and possible secondary infection. This is easiIy done by turning up a ffap of nai1 using a scalpel. Most termina1 phaIanx fractures heaI without difliculty and, as a ruIe, can be treated as soft tissue injuries. If there is an avuIsion of the extensor tendon from the distal phaIanx with a resultant “basebaIl finger,” it shouId be treated as discussed in the tendon section. The hyperextension required in treating these injuries, however, should be modified in cases in which the distal interphaIangea1 joint is involved either as a chip fracture or as a disIocation. These wiI1 usuaIIy resuIt in a stiff joint and shouId be immobiIized with the dista1 interphaIangea1 joint in a sIight degree of flexion. Middle and Proximal Phalanges. These are always treated in flexion, and position can be maintained by a pIaster of paris trough. If there is overriding of the fracture ends with

FIG. 19. Method of applying traction to fingertip. A coat hanger is incorporated in a plaster of park cast and curved so that traction is applied with the finger in the position of function. Upper iIIustration demonstrates traction wire pIaced through periosteum of dista1 phalanx of finger.

through the termina1 phalanx is usualIy adequate providing the traction wire is pIaced through the periosteum of the distal phaIanx. Adhesive traction may occasionaIIy be used but must be watched carefulIy for fear of slipping or skin necrosis. When traction is applied, it is important to remember that the fingers in the flexed position do not Iie paraIIe1 to each other but instead point approximateIy to the scaphoid tubercIe. (Fig. 20.) Frequent x-ray checks of the immobilized fracture should be performed to be sure that anterior bowing of the fracture site is not taking place, since this may interfere with function of the flexor tendons. It is we11 to emphasize that if a fracture goes into one of the joints, the prognosis is poor since there wiIl be much limitation of motion in the invoIved joint. TotaI immobiIization should not be more than three weeks. At the end of this period active motion shouId be instituted, and some form of protective splint may be necessary to prevent dispIacement of the fracture site. Metacarpal Fractures. Fractures of the base seIdom present a probIem and may be immobiIized for three to four weeks in a dorsa1 447

Hand

Surgery

spIint, being sure to keep the fingers and thumb moving. Most fractures of the shaft of the metacarpaIs can be treated by manipulation and immobiIized in a pIaster gauntlet, keeping the fingers and thumb free and moving. If the

quire reduction and immobilization in a pIaster gauntIet with the thumb extended and abducted. Bennett’s fracture is an intra-articuIar fracture dislocation of the thumb at the carpometacarpal joint, presenting a triangular frag-

a

FIG. 20. FIexed fingers point essentially to scaphoid.

fragments cannot be heId without serious bowing and overriding, open reduction is probabIy indicated. IntramedulIary pinning with a Kirschner wire offers a satisfactory means of immobiIization.82 Fractures of the neck are the most common fractures found in the metacarpa1 bones. If there is onIy sIight dispIacement of the head, the hand may be spIinted in this position. However, any serious dispIacement of the head requires manipulation. This is easily done by the maneuver described by Jahss,83 where the flexed metacarpa1 phaIangea1 joint is pressed backward in the long axis of the phaIanx. When the reduction is accompIished, the metacarpophaIangea1 joint may be immobiIized by a pIaster cast, taking care that feIt is pIaced over the extensor surface of the ffexed finger and in the space between the finger and paIm. This fracture is immobilized for three weeks and foIIowed by gradua1 active motion. Kirschner wire fixation occasionaIIy may be used to immobiIize this fracture. Tbumb Fractures. Fractures of the neck, shaft and extra-articuIar base usuaIIy re-

FIG. 21. Bennett’s fracture of thumb. (a) Fracture distocation of the carpometacarpal joint. (b) Reduction is by traction along the extended thumb with pressure over the base of the metacarpa1. (c) Fixation is obtained by traction of the abducted thumb.

ment on the inner side. The metacarpal is dispIaced and sIides down aIong the saddIe of the greater muItanguIar. This fracture should be reduced with traction and pressure over the base of the metacarpa1. (Fig. 21.) A pIaster gauntIet is applied, hoIding the metacarpa1 in extension and abduction, and traction is applied to the termina1 phaIanx. This fracture shouId be immobilized in traction for approximateIy four weeks, foIIowing which it shouId be immobiIized without traction for one or two weeks until union is firm. JOINTS

Strains of finger and thumb interphaIangea1 and metacarpophaIangea1 joints often have a 458

Surgical proIonged period of disability. These shouId be treated by immobiIization for two or three weeks in a Iight pIaster splint with the joint in a position of sIight flexion. FoIIowing this period of immobilization active motion is instituted. Disability consisting of pain, sweIIing and Iimitation of motion may take months to disappear. DisIocations of interphaIangea1 and metacarpophaIangea1 joints are usuaIIy due to hyperextension trauma with the phalanx being Reduction is usuaIIy dispIaced backward. accompIished by traction and the joint immobilized for two or three weeks in a pIaster of paris cast in a position of function. DisIocation of the metacarpophalangeal joint of the thumb is one of the most common disIocations of the hand. The phaIanx is dispIaced backward, and the head of the metacarpa1 is driven forward through a spIit in the joint capsuIe which cIoses around the bone. The tendon of the flexor poIIicis Iongus and the sesamoids, which are fairly constant on this joint, may aid further in locking the disIocation. This dislocation may be approached through an incision in the metacarpophalangea1 crease of the thumb. Through this incision the voIar pIate of the joint capsuIe is reached and divided, separating the two sesamoids permitting the reIease of the head of the metacarpa1. DisIocation of the semilunar bone usuaIIy results from a falI on the dorsiflexed hand. The Iunate bone is squeezed between the radius and capitate bones into the carpa tunne1, producing compression of the flexor tendons of the finger and the median nerve. CIinicalIy there is Iimitation of motion of the fingers with median nerve paIsy and swelIing and thickening of the volar surface of the wrist. X-rays wiII reveaI the diagnosis. If seen earIy they may be reduced by appIying traction to the fmgers and thumb, with pressure being applied to the voIar surface of the disIocated bone. After manipuIation the hand shouId be immobilized in about 43” degrees ffexion for a week to ten days, foIIowing which a new cast shouId be applied with the wrist in neutra1 position for another two weeks. If the cIosed method faiIs, the Iunate may be reduced through an incision made over the front of the wrist between the flexor carpi radiaIis on one side and the flexor tendons and median nerve on the other. FoIIowing this procedure the wrist is pIaced in flexion and incorporated in a pIaster of paris cast. If old disIocations produce 459

Review symptoms, complete excision of the lunate bone may be necessary. There are many combinations of bones involved in the numerous disIocations of the wrist. In general, when these are fresh, they can be reduced by traction and manipulation. When these are old, open reduction is necessary to restore normal anatomy. Complications of these disl’ocations include degenerative arthritis and aseptic necrosis of the carpa bones, particularly the scaphoid. SPECIAL

INJURIES

Radiation Burns. Acute burns are usuaIly the result of a single large dose. They are most commonIy seen in hands of doctors or in patients after Auoroscopy. There is edema and erythema with deep boring pain. In severe cases the skin may turn white and slough; in milder cases the redness, swelling and pain disappear.84 In a case reported by Hempelman,s5 the hands became swoIIen within thirty minutes after massive exposure, corresponding to the equivalent of from 20,000 to 40,000 roentgen units of an 80 kiIovoIt x-ray machine. The right hand blistered thirty-six hours after exposure, and destruction of the skin continued in the right hand and forearm. During the second week, just prior to the patient’s death, there was dry gangrene of the fingers of the right hand and of the left thumb. Treatment of acute burns consists of sedation for the control of pain and some bland ointment such as cold cream or lanolin with a soft dressing. Chronic radiodermatitis is manifested by atrophy, telangiectasis and keratosis of the skin. This may result in carcinoma. Treatment involves excision of the area with closure by a spIit-thickness skin graft or, if necessary, by flap grafts. . In reporting a series of such cases DaIands emphasizes the danger of giving any radiation to the hand of a growing chiId for fear of disturbing bone growth. He reported the case of a young girl who was treated with radium for hemangioma at the base of the right thumb. Radiation dermatitis deveIoped at the site of radiation and the thumb grew to only haIf the Iength of its norma size. Indelible Pencil Mbunds. Dyes from indeIible pencils may be analine dyes which are

Hand Surgery subcutaneous beryIIium granulomas of the hand in persons who had cut their hands on Buorescent Iight buIbs. The granulomas invoIved the tendon of the fingers which had to be excised with subsequent skin and tendon grafting. The granulomas consisted of fibrobIastic tissue with lymphocytes and multinuclear giant ceIIs. Although beryIIium has not been used in the making of Auorescent light buIbs since 1949, Flynn emphasizes that there are stiI1 many of these in stock and caution should be exercised in disposing of the burnedout beryIIium fluorescent Iamps. HydroJEuoric Acid Burns. Hydrofl uoric acid, which has many uses in industry, causes a deep, sIow-heaIing, painfu1 burn. In severe cases there is noticeable destruction of tissue which may continue over a period of severa days to weeks. Hydroffuoric acid has an extraordinary penetrative ability. It has been demonstrated that the intact hydrogen fluoride moIecuIe is capable of penetrating intact epidermis. Figure 22 demonstrates a recent case treated at the Boston City HospitaI. Such burns shouId be immediateIy washed with a warm solution of sodium bicarbonate and foIIowed by a soaking of the part in aIcoho1. As soon thereafter as possibIe, under general or regiona anesthesia, the soft tissues underneath the skin shouId be injected with IO per cent calcium gIuconate. This is done so that the fluorides in the tissues will be precipitated as insoIubIe caIcium Buoride.8Y The previously mentioned case was treated in this manner and resuIted in heaIing of the burned areas with epitheIization. At present there is a thin, atrophic scar in the dorsum of the hand which may have to be excised and skin grafted. Wringer Arm Injuries. This injury is incurred when an arm is caught between the roIIers of a power-driven washing machine wringer. The involved extremity is contused or crushed, depending on the type of wringer. The invoIved area becomes swoIIen and ecchyis undertaken, motic; and if no treatment severe ischemic changes may occur in the hand and forearm. DevitaIized skin wiI1 slough Ieaving granuIating wounds. X-rays are usuaIIy taken but they rareIy show fractures. MacCoIIum et aI.g0 have reported on I I 6 such of a injuries. They emphasize the importance steriIe dressing together with a pressure dressing applied with an eIastic bandage extending from the fingertips up to the axiIIa. The hand should

FIG. 22. Hydroffuoric

acid burn of right hand. Treatment with subcutaneous IO per cent caIcium gluconate.

especiaIIy toxic, causing necrosis of tissue. Such a wound heaIs very sIowIy. The initia1 treatment of these Iesions is surgical. The whoIe of the discoIored area should be excised and the resuIting wound Ieft open. Grease Gun Injuries. Hand injuries produced by the injection of grease under pressure have been numerous. The mechanism is similar in a11 cases. A grease gun with a needIe-Iike ejector is the usua1 offending agent. The operator accidentIy touches or comes very cIose to the end of the injector while the trigger of the gun is tripped. Grease is then injected into the finger or hand in varying quantities and under various pressures. It spreads diffusely throughout the tissue of the finger and hand, even going into the wrist and forearm. There is pain and swelling in the invoIved area due to the pressure of the mass, chemica1 irritation of the grease and secondary infection which may occur. Treatment at this stage invoIves use of peniciIIin to prevent secondary infection and sedation for the pain. Surgery shouId be Iimited to cautious remova of sIoughing tissue or incision of ffuctuant areas when abscesses deveIop. After the original wound has heaIed, the retained grease that is encapsuIated in the chronic infiammatory tissue may cause the formation of oIeomas. These are composed of fibrobIasts, plasma ceIIs, poIymorphonucIear ceIIs, Iymphocytes, monocytes and giant ceIIs. Treatment of these is surgical excision.87 Beryllium Granulomas. BeryIIium produces various skin Iesions such as dermatitis, cutaneous ulcers and subcutaneous granutomas. FIynrP has recently reported on two cases of 460

SurgicaI

Review

be placed in the position of function. Routine penicillin is recommended. The wound should be examined every day for the first few days to determine the extent of injury. If there are large accumuIations of fluid under the tissues, they shouId be evacuated through a surgica1 incision. If the fascia covering the muscle bundIes appears to be under severe tension, a fasciotomy shouId be performed. These wounds are sutured and a pressure dressing is re-appIied to the entire extremity. When skin is Iost, skin grafting should be done as early as possibIe. Active motion shouId be instituted early. GoIdnersl has discussed severe “ wringer ” III.

RECONSTRUCTIVE

injuries which resulted in a clawhand deformity. If the deformity invoIves skin contracture onIy, it can be readily repaired with a skin graft. If the joint is functioning we11 but the extensor apparatus is destroy.ed, tendon grafting may be of vaIue in restormg some active extension to the metacarpophaIangea1 joints. If joint function is Iimited, an attempt can be made through capsulotomy, dissection and stripping of the volar pIate of the metacarpophaIangea1 joints to restore motion. When this is not possible, fusion of the metacarpophaIangea1 joints in the position of function wiI1 be necessary. SURGERY

Reconstructive surgery involving tendons and nerves has been discussed in the previous part devoted to trauma of the hand and will therefore not be discussed here. Skin Contracture. Norma1 function of the fingers and hand may be prevented by contracture of the skin. Such contracture usuaIIy foIIows improper pIacing of skin incisions across fl exion creases, keIoid formation, severe infections, burns or tissue Ioss from trauma. The contracted tissue may invoIve skin, fascia, tendon, joints and intrinsic muscIes. The first stage of such repair requires remova1 of the underIying scar tissue with a pIastic repair of the resuItant defect. The repIacement of skin wiI1 vary with the tissue defect. If this is Iimited, mobiIization of the surrounding skin and subcutaneous tissue with primary cIosure may be satisfactory. SIiding flaps from adjacent areas may cIose the defect. This is of particuIar vaIue if the defect is on the paImar surface of the finger and hand, and the tissue can be obtained from the IateraI areas. In this case the donor site wiI1 be cIosed with a spIit-thickness skin graft. FIexion contractures of finger webs and fingers can often be corrected by Z-pIasty procedures. When the surface repIacement does not invoIve deep tissues and the defect is large, free skin grafts are usefu1. As a genera1 rule, split-thickness skin grafts are satisfactory for the dorsa1 and IateraI areas of the paIm and fingers. F&thickness skin grafts or deep split-thickness skin grafts are used on the paImar surfaces. It is essentia1 that the edges of the graft do not cross Aexion creases but are placed IateraI to such creases. When the defect

OF THE

HAND

obtained by removing the contractured skin and scar tissue is deep, invoIving tendons and nerves, it must be cIosed with Aaps. Pedicle Aaps are usefu1 but there is an increasing tendency to use singIe ffap grafts. It is essentia1 that these grafts be kept closed to avoid an open wound with subsequent edema and increased fibrosis. Contracture of the web space between the thumb and index finger may be considered as a specia1 topic. SeveraI exceIIent articIes have written concerning this subject.g2-94 been Maximum spread of the thumb is obtained when the thumb metacarpa1 is 45 degrees forward from the transverse pIane of the palm. Wounds or incisions aIong the web of the thumb (Fig. 23A) or between the base of the thumb and the thenar crease (Fig. 23B) wiI1 resuIt in contractures. After excision of the contractured area the skin can be repIaced by either a Z-pIasty or IocaI shifting if the defect is smaI1. In most cases in which the palmar surface of the hand is involved a pedicle or direct flap wiI1 be necessary, taking care that the web space is covered from hinge to hinge. If the scarred area invoIves onIy the dorsum or is not particuIarIy deep, it may be replaced by a spIit-thickness skin graft, taking the same precautions in pIacing it. Figures 24A and B show the right hand of a truck driver who suffered a severe burn of the paIm and volar surface of the fingers and thumb. The initia1 treatment was not satisfactory in that the web space of the thumb and index finger was not maintained, and skin grafting was performed too Iate. As a consequence, flexion contracture of the index, middIe 461

Hand

Surgery The etioIogy is disputed. Most authors agree that heredity has definite significance. Repeated minor trauma cannot be ruIed out as a cause, however, since it is present in a Iarge percentage of the histories obtained from patients with this disease. Skoogg6 found that the incidence of contracture was 42 per cent in a group of male epileptics. Steinbergg6 beIieves that it is a type of fibrositis. CIays7 beIieves that in a certain percentage of cases it is a true neoplasm, a ceIIuIar fibroma of the palmar fascia. The occasiona occurrence of this contracture as a sequeI to coronary artery disease must be remembered. Askeys reported seven of ten cases of postinfarctional shouIder and hand syndrome with contracture of the paImar fascia similar to Dupuytren’s. KehIss reported six cases foIIowing coronary occIusion. In three cases the changes appeared biIateralIy. AIthough the pathogenesis of this reIationship is not cIear, a review of the cardiac status of every middle-aged and eIderIy patient who is to undergo surgery for Dupuytren’s contracture shouId be undertaken. RegardIess of the cause, the palmar fascia undergoes continuous thickening involving the overIying voIar skin and a11 the prolongations of the paImar fascia into the fingers, with consequent ffexion contractures of the proximaI and middIe joints of the involved fingers. Microscopic examination shows fibrous hyperplasia of the palmar fascia. CIinicaI devetopment takes place at varying speeds. Some cases never progress over thirty or forty years, and in others there is severe ffexion which devetops within severa years. The disease usuaIIy begins as a thickening or noduIe in the skin of the palm just above the base of the ring finger associated with puckering of the skin. As it progresses it causes a flexion contracture of the ring finger. (Fig. 25.) Less commonly invoIved are the fifth finger, middle finger and thumb. In Ross and Annan’s seriesiw the fingers were invoIved as foltows: ring finger, forty-five; IittIe finger, forty; middle, tweIve; thumb, three; index, none. Dorsal knuckIe pads or noduIes over the proxima1 interphaIangea1 joints of one or more of the fingers are seen which are simiIar histoIogicaIIy to the paImar contracture. Treatment of this condition requires compIete surgica1 excision of the palmar fascia. The operation is aIways performed in a btoodIess field, and the type of incision varies with

and ring fingers and an adduction contracture between the thumb and index finger deveIoped. A tube pedicIe graft was raised from the Ieft thoracicoabdomina1 region. When it was thought that this was suffrcientIy vascuIarized to shift, the scar tissue was excised from the

FIG. 23. Contractions in the line (A) between thumb and hand will result in adduction deformity of thumb, and along line (B) witI resuIt in limitation of extension of thumb.

naIm of the hand and web sDace of the thumb and index finger, and the flap of skin inserted as shown in l%gure 24C. At a suitable interval folIowing this the tube graft was removed from theabdomen and taiIored to fit the wound. The result is shown in Figure 24D and E. A suitable web space was deveIoped and the patient can now resume his former occupation. There is stilI limitation of motion in the fingers due to the proIonged immobiIity in the ireviousty shown position. Du~uvtren’s Contracture. This is a hvDerpIasia if the paImar fascia which occ& in about 2 per cent of the popuIation. It is commonIv biIatera1 and mav be associated with a similar invoIvement of the pIantar fascia and rarely with Peyronie’s disease. It may occur at any age but is most common between thirty and seventy. It occurs about nine times as frequently in maIes as in femaIes. 1

462

SurgicaI Review

24

FIG. 24A and B. A, adduction contracture adduction contracture.

2q.B of voIar aspect of thumb due to burns. B, dorsa1 aspect demonstrating

FIG. 24C. Tube pedicIe graft raised from abdomen and applied to paIm of hand.

Hand Surgery

Ftc. 25. Dupuytren’s contracture, of fourth and fifth fingers.

right palm, demonstrating

flexion deformity

is compIete, packing is carefuIIy introduced beneath and around the siIk loop in the palm. The button is drawn into the packing by gathering up on the dorsum of the hand the two suture ends which are threaded through a second button and tied with moderate firmness over gauze to maintain snug pressure.” In the eIderIy patient it may not be advisable to perform the radica1 operation for fear of limitation of motion of the hand, and an excision Iimited onIy to the invoIved fascia may be of vaIue.lo2 Subcutaneous fasciotomy may offer paIIiative relief to such persons. Steinberg has cIaimed reIief from this disease by treatment with vitamin E; however, Kinglo could find no evidence of benefit by this treatment. Iscbemic Contractwe. Ischemia of the forearm or hand, for a temporary period of time, may result in destruction of muscles with subsequent fibrosis and contracture. When the muscIes of the forearm are involved, such a state is known as VoIkmann’s contracture. This most commonIy foIIows a SupracondyIar fracture of the humerus or fracture of the bones of the upper forearm but may foIIow any trauma to the arm. It has been seen folIowing emboIism. Although this entity was first believed to be caused by venous obstruction in the antecubita1 fossa, it is now believed that the prime factor is arteria1 insufFiciency.104~105 The clinica picture begins with pain in the forearm and hand associated with edema and cyanosis. Hypesthesias and paresthesias may

the author. The Hand Service at the Boston City HospitaI has recently been using two incisions; one extending aIong the distal palmar crease and the other folIowing the curve of the thenar eminence. During the dissection of the fascia great care must be taken that a11 the extensions of the fascia between the tendons and neurovascuIar bundles be removed. When the proxima1 phalanx of the fmger must be approached, it may be done through either a ffap or a Z-pIasty incision. If the vascuIarity of the skin flaps is compromised, suitabIe excision of skin must be performed with grafting of a fuII-thickness skin graft into the paIm. FolIowing this the hand is placed in the position of function and a pressure dressing applied for a week or ten days, foIIowing which active motion is instituted. In an attempt to avoid postoperative hematoma with consequent stiffening of the hand, TanzerlO’ has advised the use of a compression suture as foIIows: “Before the skin incisions are cIosed, a mattress suture of #ooo siIk, doubIe-armed on straight needles and incorporating a button, is passed directIy through the hand at two points. The first needIe penetrates the skin between the second and third metacarpa1 bones, passes under direct vision to one side of the neuro-vascuIar bundle and pierces the intermetacarpal space at a IeveI far enough distalward to avoid the deep voIar arch and uInar nerve emerging through the dorsal skin. The second needle is introduced in the same manner between the fourth and fifth metacarpa1 bones. After the hand closure 464

Surgical

Review

appear in the distribution of the nerves in the hand. The radial pulse is usuahy absent. Exploration of the forearm at such a stage discloses swollen, necrotic muscles with profound arterial damage or spasm. If the disease prothese degenerated muscles become gresses, atrophic and contracted, and the lingers and wrist assume a flexed position. Attempts to extend the fingers resuIt in severe pain in the forearm. As the disease process continues, there will be Jimitation of motion in the joints in the hand due to disuse. Nerve lesions may be severe with the usual manifestation of nerve injury. ‘I’reatment of this condition may be divided into the immediate and Iate treatment. As soon as this condition is diagnosed, every effort shouJd be made to restore the circulation in the invoIved extremity. If the elbow fracture was placed in acute flexion, the eIbow shouId be extended to see if the radial p&e would be restored. Following this the antecubita1 space should be explored to examine the arterial system. If the artery is completely destroyed, arteriectomy shouJd be performed. Sympathectomy may be of value in improving the circuIation, as has been observed by Foisie.‘06 CrystaI et aJ.r07 have recently presented a case in which a thrombectomy was performed twenty hours following injury. FoIlowing this procedure on the brachial artery, circulation was restored in the dista1 arterial suppIy. There was almost a complete cure of this condition. CreganrO* presents a case of prolonged arterial spasm of the brachial and ulnar arteries which was expIored nine hours folIowing a supracondylar fracture of the humerus. Examination showed the arteries to be in tight spasm with no Iocalized arteria1 injury. AI1 the smaIJer arteries were cohapsed, but the veins and nerves appeared normal. The main arteries were mobiIized and swabbed with novocain. The color of the hand improved appreciably but the arteries showed no more than slight relaxation. No pulsations were seen. The wound was cIosed, the brachia1 plexus infiltrated with novocain and the fracture reduced. The hand gradually became pink and warm but the radia1 pulse did not return for twelve hours. Six months following this there was no evidence of ischemic muscle contracture or nerve lesions. There is another schoo1 of thought on the treatment of the acute condition. Seddonrog has had experience with immediate operation on

the forearm and excision of necrotic muscle. In this way it is beheved that the contracture of the, necrotic muscIe would be prevented and the disability thereby decreased. The difliculty with this, however, is that one is not sure of the muscle regeneration. For instance, Horn and SevittlrO followed the regeneration of a tibialis anterior muscIe by muscle biopsy for weeks folIowing a rupture of the popliteal artery. At the beginning the muscle is brown, dry, friable and quite avascuJar. Histologic section of this muscle nineteen weeks after injury showed necrotic muscle with absence of nuclei and discoida1 fragmentation. A second biopsy fiftyseven weeks after injury showed no necrotic muscle in the section. Essentially a regeneration of muscle took pIace, pointing out the regenerative power of human muscle and presenting the probIem of deciding what muscIe to excise at the time of initia1 surgery. GriffIthslog suggests that perhaps the response to intravenous curare or the persistence in the muscle of injected radioactive substances might be a useful guide. Further experiments should be carried on aIong this line of reasoning. For the Iate condition, a Iong period of physiotherapy with dynamic spIinting to overcome the contractures should be foIlowed. Efforts shouId be made to restore motion in all the joints of the lingers, hand and wrist. If this is not sufficient to overcome the deformity, some operative procedure may be necessary. Tendon lengthening of the contracted tendons may be done. Nisbet 111has described a musclestripping procedure in which the contracted muscles are stripped from their origin in the forearm permitting the shortening to be overcome. Parkes112 describes an operation in which the flexor carpi radiaIis, paImaris Iongus and flexor carpi ulnaris are completely divided at the wrist to permit dorsiflexion. Tendons of the flexor digitorum sublimis are resected, and the tendons of the flexor digitorum profundus are divided high enough above the wrist to avoid retraction of the dista1 stumps into the carpal tunne1 when the fingers are fulIy extended. The tendon of the flexor pollicis longus is similarly divided to permit extension of the thumb. The tendon of the extensor carpi radiahs longus is divided at its insertion and freed for a considerable distance from the extensor carpi radialis brevis. This muscIe with its tendon is re-routed in as straight a line as possible from 465

Hand Surgery its origin to the front of the wrist, where it is buttonholed through the four tendons of the flexor digitorum profundus and fixed in the usual way. Correct tension is made at the suture line to insure that full advantage is taken of wrist movement. This operation is really a

/ FIG. 26. “Intrinsic

[ Jm

dum//

)

plus” deformity of finger. (a) Characteristic Dosition of finger: (b) forced extension of metacarpophaIangeal joint prohibits Aexion of finger; (c) ffexion of metacarpophalangea1 joint permits Aexion of Fmger.

tenodesis and it restores Aexion of the lingers by means of the trick movement of dorsiflexion. It is interesting that the lack of voluntary power of the thumb produced by this operation causes no material disability providing there is active opposition of the thumb. It is of interest that Thompson and Masimilar honey 1r3 have described a contracture to Volkmann’s contracture in the lower extremity following fracture of the femur. Bunnell58 has described a similar condition occurring in the intrinsic muscles of the hand following encasement of hands in plaster of paris or tight elastic bandages. He describes it as ischemic contracture, local, in the band. This contracture may follow damage to the 466

great vessels and may accompany Volkmann’s ischemic contracture or may occur entirely independent of it. There is a characteristic posture of the hand with the metacarpophalangeal joints held in flexion and the interphalangeal joints in extension with the straight thumb in the palm. The characteristic deformity is due to contraction of the interosseus and Iumbrical muscles. This position has been described by Bunnell as the “intrinsic plus” position. If the metacarpophalangeal joints are passively forced into extension, the distal interphalangeal joints cannot be Aexed. (Fig. 26.) However if the metacarpal joints can be held at Aexion, these distal joints can be flexed. In mild cases a splinting of the hand may overcome the deformity. However, in most cases operation will be necessary. If some interosseus function is still present, Bunnell suggests that the interosseus muscIes be separated from the metacarpaIs by periosteal dissection and allowed to advance distally to permit extension of the metacarpophalangeal joints and flexion of the two distal joints. On the other hand, if the intrinsic muscles are too fibrotic to function or if previous stripping has been unsuccessful, tenotomy of the Iateral bands of the lingers should be performed through a short Iateral incision on the dorsal aspect of each of the three finger webs until the fingers can be fully flexed with the metacarpophalangeal joints extended. When such a condition involves the web space of the thumb, there will be an adduction contracture. Various procedures may be necessary to restore normal function. The contracted skin should be excised and the intrinsic muscles stripped from the thumb. After the defect is skin grafted from hinge to hinge, ,the full thumb spread may be maintained by transfixing the metacarpals of the thumb and index finger with two Kirschner wires. At a later date, tendon transfer to restore opposition to the thumb may be indicated. Joint Contracture. Immobilization of the hand for a prolonged period of time results in stiffening of the finger joints. This may be seen in any of the aforementioned injuries. When the metacarpophalangeal joints are affected, some form of movement in the joints may be restored by either a capsulotomy or arthroplasty. Capsulotomy should be successful if there is no joint disease. X-ray should be taken of all such joints before surgery is attempted. Capsulotomy consists of excision of the collateral

SurgicaI Iigaments of the joint. If passive motion of the joint is less than expected, the anterior capsule shouId be expIored; and if it is adherent to the bones, it shouId be freed by bIunt dissection. A transverse incision of the capsule shouId not be done because subIuxation may occur, and there may be a greater degree of ankylosis than before operation. If the joints are diseased, some form of arthroplasty is indicated providing the skin and soft tissues are in good condition. Either the metacarpal head or the proxima1 centimeter of the proximat phalanx is resected, and a strip of fascia is sutured over the proxima1 bone so that its gliding surface faces the flexor and extensor tendons around the joint.l14 When the proxima1 and distal interphaIangeal joints are ankyIosed, capsutotomy is rareIy successfu1. There is probabIy no place for arthropIasty because of IateraI instabiIity in these joints. The most usefu1 procedure is an arthrodesis at an angle of moderate flexion. Occasionally amputation of a hopeIessIy ankyIosed finger may be necessary. If the interphaIangea1 and metacarpophaIangeal joints of the thumb are invoIved, an arthrodesis in the position of function is often the best procedure. When the carpometacarpal joint of the thumb is involved, severa procedures may be of vaIue. A capsuIotomy of the carpometacarpa1 joint, in addition to other procedures on the soft tissues, may restore function as suggested by Howard.g4 If the navicular bone moves normaIIy, an arthrodesis of the carpometacarpa1 joint may give a usefu1 digit. However, if the navicuIar bone is aIso ankyIosed on the carpus, an arthroplasty of the carpometacarpa1 joint may be of vaIue. The carpometacarpal joint of the thumb is a common site of osteoarthritis in the hand. In the presence of this disease x-rays will show narrowing of the joint space, subchondral condensation of bone, latera subluxation, osteophyte formation and deformation of the media1 and dista1 angIe of the muItanguIar. If the symptoms are sufficiently severe, MtilIer116 suggests that arthrodesis of this joint be performed. Gervis116 presents the opposite point of view and believes that excision of the greater m&angular is the procedure of choice for this disease. He reported fifteen cases in which this operation was performed. The resuIt was fuI1 and painIess movement of the first metacarpa1 bone. 467

Review Bone Deformity. Fractures of the fingers may heaI with malunion resuIting in poor function of the fingers and hand. Treatment wiII consist of either osteotomy and correction of the deformity or amputation of the finger. Of particuIar importance are the fractures of the thumb and index finger which may resuIt in a narrowing of the thumb web space. Malunion of Bennett’s fracture may resuIt in such a web space narrowing. Treatment consists of bone reconstruction doing either an osteotomy or a fusion of the carpometacarpal joint. Fractures of the proximal haIf of the index metacarpa1 with malunion may give a reIative contracture of the thumb web. Treatment may consist of osteotomy with proper bone aIignment. Reconstruction of Digits. Destruction of the thumb is one of the most disabIing of al1 hand injuries. ConsiderabIe attention has been devoted to reconstruction of this digit. If there is adequate Iength of the thumb stump and norma flexion of a11 the fingers, the quickest and simpIest procedure is a deepening of the web space between the thumb metacarpal and index metacarpa1 such as one wouId do for syndactylism. It may be usefu1, however, to restore length to the thumb. Lewin117 uses an iliac bone graft inserted into the stump of the metacarpal to restore Iength. Norma1 sensation in the digit is obtained by eIevating the origina skin around the thumb. The resuItant defect over the thenar eminence is covered by a splitthickness skin graft. Thumb Iength may aIso be restored, as suggested by GreeIy,‘18 by inserting a piece of rib into the metacarpal of the thumb foIlowing a tube pedicIe graft of skin and subcutaneous tissue to the thumb stump. This procedure has a disadvantage since normaI sensation is not present in the thumb. PoIIicization of an adjacent finger has been performed by several surgeons.11g,120 Marble121 believes that such pollicization shouId be done onIy with a reIativeIy deformed finger and not with a normaI finger. CIarkson122 has had experience with numerous cases in which he has transferred the great toe to the hand to repIace a thumb. Loss of a11 five digits of the hand is an extremeIy crippling deformity. Graham et aI.lz3 have described four cases of such deformity wherein they created a “Iobster cIaw” type of hand by elongating the first metacarpa1, if

Hand Surgery necessary, excising the shaft of the second metacarpa1 Ieaving onIy the base, creating a cIeft between the third and first metacarpals by bringing a rectangular ffap of skin from the dorsum of the hand through the cIeft and suturing it to the base of the paImar wedge. The paImar skin obtained by excising the second metacarpal is sutured dorsaIIy into the cleft onto the opposing surfaces of the first metacarpal. Higgins lz4 has described a proce-

dure wherein the second and third metacarpals, the Iesser muItanguIar and the body of the capitate bone are excised for a simiIar condition. Since an S-shaped incision was used for the procedure, the first metacarpal is covered with palmar skin and the third and fourth metacarpaIs with dorsa1 skin. The resultant stump in this individual had surprisingIy good grasping function and was quite suitable for manual labor.

IV. CONGENITAL

DEFORMITIES

CongenitaI deformities consist of absence, fusion, mu1tipIicity and aItered growth of parts of the upper extremity. They have been we11 discussed by BunneI123 and Barsky.lz6 A few of the deformities wiI1 be presented in this review. ABSENCE

Paraxial

OF

PARTS

Hemimelia.

CongenitaI absence of the radia1 or ulnar side of the hand may take place. In the defect of the radia1 bud there will be absence of a11or part of the radius, the radial bones of the carpus (scaphoid, trapezium, first metacarpa1) and often the thumb and adjoining finger together with defects in the soft parts aIong the radial side of the forearm. The ulna is short and thick; and as the hand grows, it deviates toward the radia1 side of the paIm until it is often at a right angIe to the forearm. Treatment invoIves proper spIinting during growth to correct the deformity with subsequent excision of contracted parts and fusion of the hand in correct alignment. A defect of the ulna bud, which is Iess frequent than the radia1, may give absence of part or a11 of the ulna, together with the pisiform, hamate and some of the other metacarpaIs and associated digits. Defects in the soft tissues on the ulnar side of the arm wiI1 take pIace. Since the radius is the most important bone in the wrist, the hand dysfunction is not as severe as with the opposite defect. Treatment is instituted according to the principles outlined for radia1 hemimelia. As previousIy mentioned, paraxia1 hemimeIia may occur only in the soft tissues. White and Jensen126 have recently reported a series of cases in which the extensor poIIicis brevis is absent biIateralIy, with the resuttant deformity of the first metacarpal bone heId in abduction and the proximal phalanx flexed forward and partially sublux’ed. There is also ulnar deviation

of the hand due to absence of this tendon. These cases are repaired by transferring the common extensor tendon of the index finger to the dorso IateraI surface of the proximal phaIanx of the thumb. Cleft Hand. This is a rare anomaIy in which there is a defect of the centra1 portion of the hand. A V-shaped cleft, which tapers proximaIIy, dividing the hand into two parts is the usual finding, the digits in each part being webbed. The middle metacarpat is usuaIIy Treatment of this condition may missing. benefit the patient. If the cIeft is too wide, its function may be improved by narrowing it. If the person’s hand is functioning with a it is probabIy more “ pincer-Iike ” movement, important to keep this movement rather than try to improve the appearance. Annular Groove. CongenitaI annular grooves may be present anywhere in the upper extremity. They may be superficial involving only skin and subcutaneous tissue, or they may involve fascia, tendons and bones, resuIting in amputation of the part. They are usuaIIy combined with some other anomaly such as syndactylism and brachydactylism. Treatment, when indicated, is directed at excising the circuIar bands and reapproximating subcutaneous tissue and skin. To prevent recurrence of the constriction, the skin incision should be made so that a circular scar does not occur. This may be done by making alternate diagona1 cuts on each skin margin down to the deep fascia, thus doing a modification of a Z-pIasty. One probabIy should not encircIe the finger compIeteIy at one operation but should do only haIf a finger at a time. FUSION

OF

PARTS

Syndactylism. In this disease there is a joining of one or more of the fingers, the middle and ring fingers being most commonly in-

4.68

Hand Surgery

FIG. 27. Syndactylism.

voIved. (Fig. 27.) AI1 the fingers may be appearance to webbed, giving a “mitten-like” the hand. This aflIiction is twice as frequent in males as in femaIes and is often associated with other defects such as poIydactyIism. Operation is usuaIIy performed when the child is three or four years of age unIess it is beIieved that the webbing is aItering the growth of the bones. The cIassic operation is the one first suggested by ZeIIer in 1810. In this the fingers are cut apart and a V-shaped flap is made on the web space of the dorsa1 and paImar surfaces. The two ffaps are sutured side by side, thus deveIoping an adequate web space. The sides of the fingers are covered by a skin graft, in which case the skin graft covering the web shouId extend onto the dorsa1 and paImar surfaces. If a doubIe nai1 is present, it shouId be split and a portion of the nai1 and its matrix on each side removed, so that a skin graft may be brought over and around the nai1 margin. If more than two fingers are fused, Barsky suggests that one has to be cautious about separating both sides of a digit. It is probabIy safer to operate on one side of the finger at a time. If the tendons are common, they should be left attached to the better finger with a tendon graft being performed on the other finger. This is a fusion of the Sympbalangism. interphaIangea1 joints, usuaIIy the middle one. An arthrodesis of the joint in the position of function is the procedure of choice if an operation is deemed advisabIe. Synostosis. Fusion of other bones of the arm may occur. ProbabIy the most numerous are those in the carpa region. 0’RahiIIy’27 has

made a survey of carpal anomaIies. PracticaIIy every conceivabIe combination of carpa fusion has been reported. The most common is the Iunate-triquetra1 fusion. For some reason this appears to be more common in the African race. Minnaar128 reported a series of tweIve such fusions which he had personaIIy seen in members of the South African Bantu. MULTIPLICITY

OF

PARTS

This deformity consists Hyperpbalangism. of an excessive number of phaIanges, the thumb being most commonly invoIved with three phalanges present. Accessory Bones. 0’RahiIIy127 has studied and reported twenty-five such bones and has attempted to standardize their terminoIogy. ALTERED

Congenital flexion

GROWTH

contracture

of fingers most often involves the fifth finger. The proximal interphaIangea1 joint is usuaIIy heId in ffexion with the other two finger joints held in extension. BunneIIz3 states that the surgica1 treatment of this is very disappointing, since a11 the tissues are involved in the contracture and it tends to recur after their excision. Bracbydactylism is a condition in which some of the phaIanges or metacarpaIs of digits are short or absent. It is often associated with other congenita1 defects of the hand. ShouI and Ritvo129 report an interesting series of three cases of brachydactylism in which the invoIved fingers had four phaIanges. Madelung’s deformity occurs when the growth of the radius falls behind that of the uIna, pro-

469

Hand Surgery ducing a volar and uInar curve of the radius. The increased growth of the ulna makes this bone Iuxate from the radius and project dorsaIIy and distaIIy, giving a cIinica1 impression of a forward disIocation of the wrist. There is aIso Iimitation of motion in the wrist. Treatment is deferred until bone growth is compIeted. FoIlowing correction of soft tissue V. TUMORS

contracture the head of the uIna is removed and a sIing pIaced around it to prevent its dislocation. The forearm is then spIinted in an overcorrected position. If the radial deviation is suf&ientIy severe, a wedge osteotomy may be necessary. Megalodactylism consisting of hypertrophy of the digits seldom is benefited by surgery. OF THE

HAND

Mucous cysts of the skin are myxomatous lesions believed to be due to mucoid degeneration of the skin. They are usuaIIy present on the dorsa1 aspect of the distal interphaIangea1 joint of the fingers, the long finger being most commonly invoIved. (Fig. 28.) The great majority of these occur in women. Since they arise in the skin, the skin cannot be moved over them. They appear as trans1ucent painIess noduIes and may be muItipIe. Microscopically, the waII is made up of coIIagen fibers which send thin, irregular trabeculae toward the center of the cyst producing a Iace-Iike pattern in which mucoid materia1 is seen. The recurrence rate folIowing surgery is high unless a margin of skin is removed around the lesion. The resuItant defect wiI1 have to be skin grafted.13r Glomus tumors are usuaily small, purplish bIue lesions characterized by excruciating pain. The slightest pressure on this Iesion may cause severe pain. They arise from the glomus, a normal end organ consisting of an arteriovenous anastomosis containing smooth muscIe ceIIs and large clear ceIIs referred to as epithelioid or glomus ceIIs. The glomus controls arteriovenous circutation within the fingers and extremities and controls the temperature of the body. These organs are distributed widely over the body. They occur most frequentIy in the nai1 beds and fingertips and secondly in the volar aspects of the first, second and third phalanges of the upper and Iower extremities. The tumors are usuaIIy very small, being a few millimeters in diameter, and if not visibIe may be picked up by the pin test.rz2 However, they have been reported up to 3 or 4 cm. in diameter.133,134 The subungual gIomus, which is the most common variety, may occasionally erode the bone of the underIying phaIanx.135y136 Treatment is surgica1 excision, and recurrences following surgery have not been reported. Giant cell tumors of tendon sbeatbs (xanthoma) occur most often in the digits as cIearIy defined

PracticalIy every known tumor can occur in the hand; therefore it wiI1 be the purpose of this review to comment on the tumors more commonly found in this region. Ganglia are cystic tumors which occur about the joints of extremities. They are probabIy a mucoid degeneration of the connective tissue of the joint simiIar to adventitious bursas.r30 Trauma may be a factor in this degeneration. They are composed of a fibrous, connective tissue waI1 with contents resembling soft jeIIy. They never become malignant. They are most commonly observed about the wrist joint on the dorsal aspect between the Iong extensor of the thumb and index finger. The next most common site is on the volar aspect of the wrist between the tendons of the flexor carpi radiaIis and the brachioradialis. In this particuIar Iocation care must be taken to avoid damaging the radial artery at time of surgery. They can aIso arise on the deep puIIeys over the Iong flexor tendons of the fingers and on the dorsum of the interphalangeal joints. Treatment is indicated when they cause pain or cosmetic deformity. SurgicaI excision shouId be done, taking care to remove a flange of joint capsuIe around the base of the tumor. Epidermoid cysts or implantation cysts occur in peopIe who traumatize their hands. They are commonly seen in laborers, carpenters, gardeners, etc., and are present on the patmar aspect of the hand or lingers, co&ring themselves solely to the skin. It is beIieved they are due to impIantation of surface epithelium into the deeper Iayers of the skin. On microscopic section the waIIs of these cysts are composed of fibrous tissue with an inner Iayer of squamous epitheIium which may show Iaminated keratin. Treatment is complete surgica1 excision. Sebaceous cysts may occasionaIIy be present on the dorsum of the hand or fingers. They are never seen on the paImar surfaces since sebacevus glands do not occur in this area. 470

SurgicaI

Review

FIG. 28. Mucous cyst, left third finger. Fig. 29. Giant ceII tumor. FIG. 30. Epidermoid carcinoma, dorsum right hand.

round noduIes I cm. in diameter.

(Fig. 29.) They invoIve the volar and dorsa1 aspects of the fingers with equal frequency. There is a peak incidence in the fourth decade, women being afIlicted more than men. MicroscopicalIy, choIestro1 deposits may be present in a stroma of deepIy eosinophiIic connective tissue containing giant ceIIs and occasiona foam ceIIs.

They may occasionaIIy erode bones. Treatment is surgica1 excision.137 Carcinoma may occur in the hand and upper extremity, (Fig. 30.) CIarkel38 has reviewed 214 cases of primary carcinoma of the extremity seen at the Barnard Free Skin and Cancer HospitaI from 1925 to 1940. This comprised 4 per cent of a11 the cases of skin cancer seen 47’

Hand Surgery tipIe. X-rays of the enchondromas revealed the so-caIIed bone cyst with the cortex expanded and thinned. The ecchondromas occurred with equal frequency on the phaIanges and metacarpats at the insertion of a tendon usually on the proxima1 side. X-rays showed the eIevation of bony structure appearing at one end of a bone. Treatment of both enchondromas and ecchondromas is conservative and limited to surgica1 excision. If there is not sufficient bony she11 left in the shaft of a bone, bone grafting may be necessary. Osteoid osteomas are bone lesions characterized by pain and a definite x-ray appearance consisting of radioIucent centra1 nidus with a surrounding osteosclerosis. The centra1 nidus may be a few milLmeters in diameter. Since Jaffe140 described these Iesions in 1935, much controversy has arisen concerning their true nature. They have many of the elements of inflammation and neopIasm. CarroI1141 has recentIy reported six cases of osteoid osteoma found in the hand and coIIected twenty-two cases from the Iiterature. These Iesions were a11 cured by surgica1 excision. Pyogenic granulomas consisting of friable granuIation tissue and often resembling tumors may occur at the site of wounds and incisions. Treatment is by excision or cautery.

during this period. Eighty-five per cent of these cases occurred in the upper extremity, the majority occurring in maIes. The maximum incidence took pIace in a group of patients seventy years of age or oIder. The great preponderance of Iesions presented themseIves on the dorsum of the hand. There appeared to be a definite reIationship to exposure to the sun, since 163 of the Iesions of the upper extremity were squamous ceI1 carcinomas and eighteen were basal ceI1 Iesions. Treatment was by wide IocaI excision or amputation. The decision to amputate depended on the fixation of the Iesion. If Iymph nodes were feIt in the epitrochlea region or in the axiIIa, an axiIIary node dissection was performed. The prognosis in this series was good with regard to the upper extremity. In a foIIow-up of 136 cases there was a surviva1 rate of g3 per cent when the lymph nodes were not invoIved. In eIeven axillary dissections reveaIing positive nodes the surviva1 rate was 66 per cent. Cartilaginous tumors of the hand have been recentIy reviewed by SheIIito and Dockerty.13s Forty-two cases found at the Mayo CIinic were thirty being enchondromas and reviewed, tweIve ecchondromas. The enchondromas were found in the smaI1 bones of the phaIanges in twenty-five cases and in the metacarpa1 bones in fifteen cases. Two were found as tumors of tendon sheaths. Five of the tumors were mulVI. VASCULAR

DISEASES

OF THE

Trauma may disturb the circulation of the hand by direct injury to an arteria1 trunk or by reflex sympathetic vasospasm. VascuIar injuries in the upper extremity comprised about one-third of a11 the vascuIar injuries in WorId War II and the Korean War. In WorId War II gangrene requiring amputation of an extremity occurred in 26.5 per cent of brachia1 artery injuries, in 43 per cent of axiIIary artery injuries and in 28.6 per cent of subcIavian artery injuries. The resuIts foIIowing brachia1 artery injuries depend on whether or not the profunda branch is intact. Injuries above the profunda resulted in a 53 per cent amputation rate, and beIow the profunda in a 25.8 per cent amputation rate.142 Jahnke and SeeIeyl43 reported on a series of seventy-seven injuries that occurred in the Korean War. They approached the vascuIar injury through cIassica1 surgica1 incisions

HAND

(TRAUMA)

described by previous writers and, if possible, did not go through the initia1 wound. About I cm. of Iacerated artery was removed from each end, since examination of such tissue demonstrated histotogic changes due to trauma even at this distance from the origina injury. The artery was we11 mobiIized and the adventitia was stripped from the artery proximaIIy and distaIIy for many inches, in some cases up to IO inches. When necessary, important coIIatera1 branches were divided to permit mobitization. Partial flexion of extremities was utiIized to permit sutures without tension. The usua1 CarreI everting anastomosis was used. It was deemed imperative that the anastomosis be covered with muscIes or fascia at the compIetion of the procedure! Using this technic, a vein graft was needed in only four of the reported cases. The result of this method of treating the traumatic vascular injuries was 472

SurgicaI

FIG. 31. Digital FIG. 32. Gangrene

gangrene resulting

3’ resulting from

from Ievophed

digital

nerve

infusion

Review

block

I per cent novocain

32 sotution

with

epinephrine.

in forearm.

extremely gratifying, since no gangrene occurred in the major arterial injuries of the upper extremity. CHEMICAL

with

infusion. A pIastic catheter was pIaced in a vein IO inches proximaIIy and introduced about in the arm. At the site at the tip of the catheter an area of gangrene was produced foIIowing infusion of this soIution.

GANGRENE

Ergot preparations have Iong been known to produce gangrene in extremities. Cases of digital gangrene of the upper extremity have been reported folIowing the use of ergotamine tartrate.14” Contraindications to the use of this drug are pre-existing sepsis, obIiterative vascular disease and cardiovascular disease. It should be empIoyed with caution in cases of hepatic or renaI disease and hypersensitivity to the drug. Digital nerve block occasionaIIy resuIts in gangrene of a finger. This is usuaIIy due to epinephrine in the novocain soIution, but secondary factors such as the use of a tourniquet or too much injected soIution may pIay a role. When performing a digital nerve bIock for anesthesia of a finger, no more than I to I ;/s cc. of I per cent novocain shQuId be used for the bIock with no tourniquet being used.145 Figure case of digita 3 I shows a previousIy unreported gangrene following a digital bIock in which epinephrine was used in the novocain soIution. This brings the tota number of such cases personaIIy seen by the author to nine, eight of which have been previousIy reported.146 Pbenol dressings were frequentIy used on fingers and toes in the past but resulted in so many cases of gangrene that their use has been discontinued. The present use of Ievophed@ solution wiI1 occasionaIIy resuIt in gangrene at the site of intravenous infusion. Figure 32 demonstrates a patch of gangrene resuIting from a Ievophed

FROSTBITE

Frostbite wil1 resuIt in amputation of digits in approximateIy IO per cent of miIitary cases.‘46 It may resuIt from one or more of several factors: direct injury from freezing, edema of the hyperemic phase occurring soon after thawing and vascuIar occIusion by aggIutinative thrombi. Much experimenta work has been done in searching for a better method of treatment of this condition. Heparin was suggested to prevent the vascular changes but resuIts are conflicting. Recently, Lewis and Moenl47 reported that heparinized experimental animals showed as much gangrene as other animaIs, and the death rate in this group was higher than in the contro1 groups. AIthough it was held for years that the part shouId be thawed sIowIy, recent work by Shumacker and KunkIer148 has shown that rapid thawing in experimental animaIs may resuIt in less gangrene than spontaneous thawing. GIenn et aI.14g have recentIy reported on the treatment of frostbite by adrenocorticotropic hormone, but they could find no significant therapeutic affect on severe coId injury. UntiI the efFicacy of other methods of treatment is proven, frostbite is treated at the Boston City HospitaI by appIying Ioose sterile administering chemotherapy and dressings, adopting a poIicy of cautious, watchfu1 waiting. 473

Hand Surgery foIlowed consisting of sympathetic bIocks and vasodilating drugs. RareIy, if there is underIying obIiterative vascuIar disease, gangrene *may occur as seen in Figure 34. Buerger’s disease rareIy affects the upper extremity. SiIbertlbl reported on a group of

Only dead tissue is excised! In most cases seen in civiIian practice gangrene does not occur, and the effected superficia1 tissues wiI1 spontaneousIy peel away leaving reIativeIy norma tissue underneath. OccasionaIIy spastic phenomena may be present in such extremities for

BOSfON CITY

MASS. GENE&?L

12%

SUP. MESENTERIC

e

87%

2%

5.2%

23 ‘k 9% 7% 8% 4%

6.9% 33% 4.6% 87% 8.f%

I2 %

23.2% 8.7%

Sites of periphera1arteria1 emboli.

months to years after the injury and may be reIieved by sympathectomy. OCCLUSIVE

3%

9%

POPLITEAL

FIG. 33.

_

/8X

DISEASE

Arterial emboli lodge in the upper extremities in a variabIe percentage of cases. In a series of 172 arteria1 emboli cases reviewed at the Massachusetts Genera1 HospitaI by Warren and Linton,lm the upper extremity was invoIved in 13.9 per cent of the cases. In a series of IOI peripheral emboIi cases reviewed at the Boston City HospitaI, the upper extremity was involved in onIy 5 per cent of the cases. (Fig. 33.) The source of arteria1 embolism is usuaIIy a diseased heart with auricuIar fibriIIation. In a series of fifty-five cases seen at the Boston City HospitaI the etiology was arterioscIerotic heart disease in twenty-six cases; rheumatic heart disease, seventeen cases; hypertensive heart disease, four cases; bacteria1 endocarditis, three cases. In four cases an arterioscIerotic pIaque of the aorta predisposed to emboIism. In one case there was a patent foramen ovaIe in which the source of the embolus was phIebitis of the right iliac vein. Upper extremity emboii rarely resuIt in therapy should be gangrene. Conservative

474

1,400 patients with this disease, in which onIy five patients had major amputations of the upper extremity. HamIin et aI.ls2 reviewed a series of 180 cases at the Massachusetts Genera1 HospitaI and found that only 6 per cent required amputation of the fingers, with no amputation above the IeveI of the finger being required. Treatment consists of sympathectomy, cessation of smoking and control of sepsis with antibiotics. Obliterative arteriosclerosis resuIts in gangrene in upper extremities in a very smaI1 percentage of cases. Treatment is usuaIIy conservative.

SPASTIC

DISEASES

Raynaud’s disease is characterized by a symmetric arteria1 spasm of the fingers when stimuIated by coid or excitement. (Fig. 35.) AIthough it seIdom goes on to gangrene, it may be extremeiy disabIing. Treatment consists of administering vasodiIator drugs such as roniacoI@ and priscoI@ to the mild cases and performing a sympathectomy on the more severe cases. Although the Iatter does not necessariIy cure the disease, it gives great reIief in many cases. This is especialIy true if there

Surgical

Review

FIG. 34. Gangrene of hand resulting from embolus in arteriosclerotic

FIG. 35. Raynaud’s

disease demonstrating

is marked coldness and sweating of the extremities between paroxysma attacks. RefEex vasospasm may be secondary to many conditions such as cervica1 ribs, scaIenus anticus syndrome, coronary occIusion and trauma. Figure 36 demonstrates the right hand of a dentist who accidentIy punctured his thumb whiIe injecting novocain solution. In-

symmetric

extremity.

arterial spasm.

fection occurred around the punctur ‘e site which disappeared in two weeks. Subseq ue ntIy the hand became weak and coId, and n8ecirosis of the tips of the thumb, index and Imi ddle fingers developed. Physical examinatic on reveaIed absent pulses in the wrist and antecubita fossa. A blood pressure was unc ,bl :ainabIe in the right arm. Treatment was ins1:it uted 475

Hand Surgery

FIG. 36. Reflex sympathetic dystrophy resulting in gangrene of tips of thumb, index and middle fingers in a dentist who injured right thumb at work.

FIG. 37. Digital

gangrene

devetoping

shortIy

FIG. 38. Gangrene of upper extremity hemolytic streptococcus.

after onset of virus pneumonia.

resulting

476

from massive

infection

with

SurgicaI

Review entering the hospita1. Infection deveIoped and spread to the entire forearm. The hand and fingers were cyanotic, and no puIse could be feIt in the wrist. Several incisions were made and creamy pus was obtained which cultured hemoIytic streptococcus. On entry he was placed on peniciIIin therapy, but the circulation in the arm did not recover. ExpIoration of the antecubital fossa was performed which reveaIed the brachia1, radia1 and uInar arteries to be in intense spasm. Saline compresses over these vesseIs caused some pulsation to return. A periadventitial sympathectomy was performed, and at the concIusion of the procedure the bIood vesseIs appeared to regain some puIsation. Numerous steIIate bIocks were performed but they did not appear to affect the situation. The hand and forearm progressed to gangrene and the patient required an emergency guiIIotine amputation of the forearm with a subsequent revision of the amputation stump. Examination of the amputated extremity revealed no thrombosis in the radial or uInar arteries, which were found to be in intense spasm. One other factor which may have been of importance in the pathogenesis of this condition was the fact that a11 the superficia1 veins of the forearm were obIiterated by thrombosis due to the numerous previous narcotic injections. It is we11 known that extremities invoIved with phIebitis are Iess tolerant of infection than norma ones.

twenty-three days after the initiat injury and consisted of sympathetic bIocks, prisco1, roniacol and Iocal treatment to the necrotic fingertips. Within severat days a faint puIse became perceptible in the right wrist. The hand gradually improved, with the bIood pressure in the right arm returning to 105/8g compared to the Ieft arm of 140/83. The fingertips healed and there was no Iimitation of motion in the fingers or intermittent cIaudication in the forearm on resuming work. INFECTION

Systemic infection may give rise to severe paroxysms with marked vasoconstrictor activity. It is conceivabIe that such severe vasoconstriction couId damage the intima of the blood vessels with subsequent thrombosis. This may expIain some of the cases of gangrene of the fingers which have resulted from influenza, virus pneumonias, etc. Figure 37 is the picture of an eIderIy man who deveIoped acral gangrene approximateIy one week after the onset of virus pneumonia. This resulted in amputations of the portions of the finger which are demarcated in the photograph. No circuIating aggIutinins were found in this patient. Infection IocaIized in an extremity may Figure 38 demonstrates resuIt in gangrene. such a case. This was a fifty-seven year oId white morphine addict who injected heroin into his Ieft arm near the elbow four days before VII.

PAINFUL

STATES

OF THE

HAND

wiI1 do much to diminish any painfu1 experiences which might be associated with such a sensation. In the great majority of cases the phantom Iimb is of no consequence; but rarely if there are emotiona or psychiatric problems, such sensations may be contorted in the centra1 nervous system to a definite painfu1 phenomenon. Treatment of such cases shouId be aIong psychotherapeutic lines. Amputation neuromas have been mentioned in a previous section. They may cause exquisite pain in an extremity and set up a reaction of pain aIong the central nervous system pathways, so that an entire extremity can become painful. Such neuromas shouId be carefully sought for by examination of the wound, using a small paIpating area such as the bIunt point of a pencil. When there is definite evidence of a

There are severa conditions which produce painfu1 states of the upper extremity, and these should be carefully distinguished from each other. Disuse of a part, with or without ischemia of soft tissues, will Iead to Iimitation of motion of joints and atrophy of the soft tissues. Attempted use of such an extremity may resuIt in pain. This type of pain is due to disuse atrophy and may be caIIed dystrophic pain. Treatment consists of physiotherapy to restore motion to the affected part. One sees this more commonly in the elderly individual or in those individuaIs with a rheumatoid diathesis. Amputation of a part aImost universely resuIts in some manifestation of the pbantom limb. The affected person feeIs that the amputated part is present. Reassurance by the personnel involved in treating such a patient 477

Hand

Surgery

1ocaIized spot in the scar that will cause severe pain and is associated with paresthesias, operation is indicated. At times the neuroma itseIf may be feIt as a discrete mass. Correct surgery demands excision of the neuroma with impIantation of the proxima1 nerve either in soft tissues or in bone. BIind excision of scar tissue is of no avail, since the neuroma will reinsert itself in the subsequent scar. Such painful neuromas are often confused with the phantom Iimb syndrome since they may appear simuItaneousIy with it. Sometimes excision of an amputation neuroma will retieve a painfu1 phantom. This does not imply that the phantom limb syndrome is due to the painful neuroma. It is onIy that the painfuI neuroma so excites or stimuIates certain areas of the central nervous system that the phantom sensation becomes painful. Routine wound revisions are of no value in the treatment of phantom limb. They are of value only when there is a definite painful amputation neuroma which shouId be treated as such. Painful amputation neuromas shouId not be confused with causaIgia. Pain produced by them shouId not be named “minor causalgia” since this onIy adds to the confusion. Sympathectomy is of great vaIue in causalgia. It is of no value in the amputation neuroma syndrome. In fact, the dry skin produced by the operation further alters sensory patterns reaching the central nervous system and may increase the pain. The spread of pain from the amputation neuroma to invoIve the entire extremity may be explained by the fiber interaction in injured nerves which has been studied by Granit et aI. and RosenbIueth.154 Another theory is that the painful nerve impuIses so stimuIate or excite the internuncia1 pool of the spina cord that norma impuIses reaching this area from the periphery are interpreted as painful. Such couId also occur in higher regions of the centra1 nervous system. A reflex may take pIace by way of the sympathetic nervous system folIowing trauma, resulting in ischemia of the part. This was mentioned in the previous section on reffex arteriospasm. Such cases may be associated with a variabIe amount of pain due to ischemia and dystrophy and has been named refiex sympathetic dystrophy. Treatment of these cases is by sympathetic bIock and sympathectomy. If the patient’s condition does not permit this,

various drugs such as priscoi and roniaco1 may be of value. Causalgia is the definite clinical entity which may fohow nerve injury. It is a spontaneous pain, hot and burning in character, aggravated by temperature changes, emotions, etc. The involved part is extremely sensitive to touch or even to the suggestion of being touched. It may lead to profound changes in the emotional state of the patient. The cause of this painfu1 state is basically unknown, although a short-circuiting between sympathetic and sensory nerves at the site of injury, as suggested by Doupe et aI.,155 explains many of the clinical characteristics. MayfieId5r observed 105 causalgia patients at the Percy Jones General Hospital during World War II. They comprised 5 per cent of a11 patients admitted to this hospital with peripheral nerve injuries. He confIrmed the fact that sympathectomy brought complete rehef of pain whenever it was completely performed. Sympathetic nerve bIock with procaine produced dramatic temporary relief of the causalgia, but in none of his cases did it give permanent relief even when repeated six to eight times. Shumacker et aI.,rb6 in a review of ninety cases of causalgia seen at the Mayo General Hospital in World War II, had a somewhat different experience. They found that in twenty-one of eighty-three patients in whom one or more sympathetic nerve blocks were performed, permanent reIief of symptoms was obtained. REFERENCES I. MELENEY, F. L. and JOHNSON, B. A. The cIinica1

2.

3.

4. 5.

6.

7.

478

signihcance of the increasing existence of organisms to the antibiotics. Surg., Gynec. @ Obst., 97: 267-276, 1953. JAWETZ, E. Therapeutic use of combinations of antibiotic agents. New York State J. Med., 53: 12281233, 1953. MELENEY, F. L., SHAMBAUGH, P. and MILLEN, R. S. Systemic bacitracin in the treatment of progressive bacterial synergistic gangrene. Ann. Surg., 131: 129144, 1950. WILSON, B. Necrotizing fasciitis. Am. Surgeon, 18: 416-431, 1952. MASON, M. L. and KOCH, S. L. Human bite infections of the hand. Surg., Gynec. Ed Obst., 51: 591-625, 1930. LEVIN, I. A. and LONGACRE, A. B. Antibacteria therapy in infections resulting from human bites. J. A. M. A., 147: 815-817, 1951. BICKEL, W. H., KIMBROUGH, R. F. and DAHLIN, D. C. Tuberculous tenosynovitis. J. A. M. A., 151: 31-35, ‘953.

Surgical

Review 32. MASON, M. L. Primary and secondary tendon Suture. SUrg., Gy?XC. &+Obst., 70: 392-402, 1940. 33. FLYNN, J. E. Persona1 communication. 34. PRATT, D. R. Internal splints for cIosed and open treatment of injuries of the extensor tendon at the distal joint of the linger. J. Bone fl Joint .%rg., 34A: 785-788, 1952: 35. TREVOR, D. Rupture of the extensor pollicis Iongus tendon after CoIIes fracture. J. Bone ti Joint Surg., 32B: 370-375, 1950. 36. FURLONG, R. J. Discussion of articIe by Trevor.35 37. GLADSTONE,H. Rupture of the extensor digitorum communis tendons folIowing severely deforming fractures about the wrist. J. Bone @ Joint Surg., 34A: 698-700, 1952. 38. JAMES, J. I. P. A case of rupture of flexor tendons secondary to Kinebock’s disease. J. Bone P! Joint Surg., 31B: 521-523, 1949. 39. ALLEN, H. S. FIexor tendon grafting to the hand. Arch. Surg., 63: 362-369, 1951. 40. FLYNN, J. E. Flexor tendon grafts in the hand. New England J. Med., 241: 807-812, 1949. 41. BOYES, J. H. Flexor-tendon grafts in the fingers and thumb. J. Bone CY Joint Surg., 32A: 489-499, I 950. 42. LAPIDUS, P. W. and FENTON, R. Stenosing tenovaginitis at the wrist and fingers. Arch. Surg.,

8. GIRDWOOD, W. MultipIe cystic tuberculosis of bone. J. Bone @ Joint Surg., 35B: 285-287, 1953. g. KLAUDER, J. V. Erysipelothrix rhusiopathiae septicema: diagnosis and treatment. J. A.M. A., *22: 938-943. ‘943. rhusiopathiae : IO. WOODBINE, M. Erysipelothrix bacteriology and chemotherapy. Bact. Rev., 14: 161-178, 1950. I I. MCVAY, L. V. and SPRUNT, D. H. Treatment of actinomycosis with isoniazid. J. A. M. A., 153: 95-98, 1953. 12. BOLTON, H., FOWLER, P. J. and JEPSON, R. P. Natural history and treatment of pulp-space infection and osteomvlitis of the terminal phalanx. J. Bone CY Jo&t Surg., JIB: 499-504, ‘949.

13. ROBINS, R. H. C. Infections of the hand. J. Bone @ Joint Surg., 34B: 567-580, 1952. 14. SCOTT, J. C. and JONES, B. V. ResuIts of treatment of infections of the hand. J. Bone CYJoint Surg., 34B: 581-587, 1952. 14. , PILCHER. R. S.. DAWSON. R. L. G.. MILSTEIN. B. B. and RIDDELL, A. G. Infections of the fingers and hand. Lancet, I : 777-783, 1948. 16. ISELIN, M. Surgery of the Hand. EngIish Edition. London, 1940. J; & A. ChurchiII Lid. 17. I)OWNING. J. G. Barber’s DiIonidaI sinus. J. A. M. A., 148: 1501, 1952. 18. KAPLAN, E. B. Functiona and Surgical Anatomy of the Hand, 1st ed. PhiIadeIphia, 1953. J. B. Lippincott Co. IO. FLYNN. J. E. CIinical and anatomica investieations’of deep fascia1 space infections of the hand. Am. J. Surg., 55: 467-475, 1942. 20. KANAVEL, A. B. Infections of the Hand, 7th ed. Philadelphia, 1939. Lea & Febiger. 2 I. SCHELDRUP,E. W. Tendon sheath patterns in the hand. Surg., Gynec. ti Obst., 93: 16-22, 1951. 22. MOSES, W. R. Diagnosis of acute Aexor tendon tenosynovitis. Surg., Gynec. ti Obsr., 82: IOI, 1

64: 475-486, ‘952. 43. BURMAN, M. Stenosing tendovaginitis of the dorsa1 and voIar compartments of the wrist. Arch. Surg., 65: 752-762, 1952. 44. ENGEL, D. Trigger linger produced by excessive heat. Surgery, 26: 659-664, 1949. AS. SPRECHER. E. Trieeer thumb in infants. J. Bone 0 Joint’Surg., 3-1-A: 672-674, 1949. 46. FINKELSTEIN, H. Stenosing tenovaginitis at the radial styIoid. J. Bone @ Joint Surg., 12: 509-

I

540, 1930. 47. COHEN, B. R. De Quervain’s disease. J. Bone Ed Joint Surg., 33B: 9699, 195 I. 48. MURPHY, I. D. An unusual form of De Quervain’s syndrome. J. Bone @Joint Surg., 31A: 858-859,

1946.

23. BUNNELL, S. Surgery of the Hand. PhiIadeIphia, 1944. J. B. Lippincott Co. 24. ROUVIERE, H. Anatomy of the Human Lymphatic System. Translated by M. J. Tobias. Ann Arbor, Mich., 1938. Edwards Brothers, Inc. 25. FLYNN, J. E. Problems with trauma to the hand. J. Bone # Joint Surg., 35A: 132-140, 1953. 26. WECKESS, E. C., SHAW, B. W., SPEARS, G. N. and SHEA, P. C. A comparative study of various substances for the prevention of adhesions about tendons. Surgery, ;5: 361-369, 1949. 27. GONZALEZ, R. I. Experimental tendon repair within the flexor tunneIs. Surgery, 26: rSI--1g8,rg4g. 28. GRANT, G. The effect of cortisone on healing of tendons in rabbits. J. Bone @ Joint Surg., 35A:

‘949. 49. HOWARD, L. D., PRATT, D. R. and BUNNELL, S. The use of compound F (hydrocortone) in operative and non-operative conditions of the hand. J. Bone &+Joint Surg., 35A: gg4-1002, 1953. 50. BURMAN, M. Tendinitis of the insertion of the common extensor tendon of the finger. J. Bone fl Joint Surg., 35A: 177-178, 1953. 5 I. SEIDENSTEIN,H. Acute pain in the wrist and hand associated with caIcific deposits. J. Bone @e Joint Surg., 32A: 413-418, ;950. 62. PHALEN. G. S. Calcification adiacent to the uisiform Lone. J. Bone CYJoint S&g., 35A: 57~‘583, 1952. 53. DENNY-BROWN, D. Importance of neura1 fibroblasts in the regeneration of nerve. Arch. Neural. &+Psycbiat., 55: 171-215, 1946. 54. POLLOCK,L. J., GOLDSETH,J. G. and ARIEFF, A. J. Strength-interval curves and repetitive stimuli in electrodiagnosis. Surg., Gynec. &+ Obst., 84: 1077-1082, 1947. 55. ROWNTREE, T. Anomalous innervation of the hand muscIes. J. Bone Ed Joint Surg., 3 IB: 5o5-510, ‘949.

525. r953. 29. GONZALEZ, R. I. Experimental tendon repair within the flexor tunneIs. J. Bone 0 Joint Surg., 35A: 991-993. 1953. 20. MASON. M. L. and ALLEN, H. S. Rate of healing

of tendons. Ann. Surg., I 13: 424-459, 1941. 31. JENNINGS, E. R., M,ANSBERGER, A. R., JR., SMITH, E. P., JR. and YEAGER, G. H. A new technique in primary tendon repair. Surg., Gynec. @ Obst., 95: 597-600, 1952.

479

Hand Surgery 79. TANZEK, R. C. Reconstruction of the burned hand. New England J. Med., 238: 687-691, 1948. 80. FLYNN, J. E. Burned and traumatized hands. Arch. Surg., 54: 249-268, 1947. 8 I. WATSON-JONES, R. Fractures and Cther Bone and Joint Injuries, 2nd ed. Baltimore, 1941. Williams & WiIkins Co. 82. VOM SAAL, F. H. Intramedullary fixation in fractures of the hand and fingers. J. Bone TVJoint Surg., 35A: 5-16, 1953. 83. JAHSS, S. A. Fractures of metacarpals; new method of reduction. J. Bone ti Joint Surg., 20: 178186, 1938. 84. BROWN, J. B., MCDOWELL, F. and FRYER, M. P. Surgical treatment of radiation burns. Surg., Gynec. @ Obst., 88: 609-622, 1949. 85. HEMPELMANN,L. H. Acute radiation injuries in man. Surg., Cynec. @ Obsr., 93: 385-402, 1951. 86. DALAND, E. M. Radiation damage to normal tissues in the diagnosis and treatment of nonmalignant conditions and its surgical repair. New England J. Med., 244: 959964, 1951. 87. BYRNE, J. J. Grease gun injuries. J. A. M. A., 125: 405-407, 1944. 88. FLYNN, J. E. Subcutaneous beryllium granuIomata of the hand. Ann. Surg., 137: 265-271,

56. MURPHEY, F., KIRKLIN, J. W. and FINLAYSON,A. I. Anomalous innervation of the intrinsic muscles of the hand. Surg., Gynec. ti Obst., 83: 15-23, 1946. 57. MAYFIELD, F. H. Causalgia. Am. J. Surg., 74: 522-526, 1947. 58. BUNNELL, S. Ischemic contracture Iocal in the hand. J. Bone EdJoint Surg., 35A: 88-101, 1953. 59. MAYER, J. H., JR. and MAYFIELD, F. H. Surgery of the posterior interosseus branch of the radial nerve. Surg., Gynec. e”r Obst., 84: 979-982, 1947. 60. LEARMONTH, J. R. Technique for transplanting the ulnar nerve. Surg., Gynec. @ Obst., 75: 792-793, 1942. 61. DANDY, W. E. A method of restoring nerves requiring resection. J. A. M. A., 122: 35-36, 1943. 62. JONES, R. II. On suture of nerves and alternative methods of treatment by transpIantation of tendon. Brit. M. J., I : 641-643; 679-682, 1916. 63. SCUDERI, C. Tendon transplants for irreparabIe radiat nerve paralysis. Surg., Gynec. @ Obst., 88: 643-65 19‘949. 64. BUNNELL, S. Reconstructive surgery of the hand. &i-g., GyntT. FY Obst., 39: 259-274, 1924. 65. KIRKLIN, J. W. and THOMAS, C. G. Opponens transplant. Surg., Gynec. c+? Obst., 86: 213-223,

1953. 89. DALE, R. H. Treatment of hydrofluoric acid burns. Brit. M. J., I : 728-732, 1951. 90. M CC LLUM, D. W., BERNHARD, W. F. and BANNER, R. L. The treatment of wringer-arm injuries. New England J. Med., 247: 750-754,

1948. 66. GOLDNER, J. L. and IRWIN, C. E. Analvsis of paralytic thumb deformities. J. Bone & Joint Surg., 32A: 627-639, 1950. 67. THOMPSON,C. T. A modified operation for opponens paraIysis. J. Bone @ Joint Surg., 24: 632-640, 1942. 68. BROOKS, D. M. Inter-metacarpal bone grafts for thenar paraIysis. J. Bone ti Joint Surg., 31B:

9’.

5* 1-5’7, 1949. 69. SMILLIE, I. S. IntermetacarpaI fusion. J. Bone Ed Joint Surg., 35B: 256-257, 1953. 70. BRAND, P. W. The reconstruction of the hand in leprosy. Ann. Roy. Coil. Surgeons England, 2: 350-361, ‘952. transplantations in 71. RIORDAN, D. C. Tendon median-nerve and ulnar-nerve paratysis. J. Bone ti Joint Surg., 35A: 312-320, 1953. 72. PHALEN, G. S. Spontaneous compression of the median nerve at the wrist. J. A. M. A., 145: I 128-1132, 1951. carpal 73. WATSON-JONES, R. Leri’s pleonosteosis, tunnel compression of the median nerves and Morton’s metatarsalgia. J. Bone @ Joint Surg., 31B: 560-571, 1949. 74. MCGOWAN, A. J. The resuIts of transposition of the ulnar nerve for traumatic uInar neuritis. J. Bone @ Joint Surg., 32B: 293-301, 1950. 75. BROOKS, D. M. Nerve compression by simpIe ganglia. J. Bone ti Joint Surg., 34B: 391-400, ‘952. 76. KUTLER, W. A method for fingertip amputation. J. A. M. A., 133: 29-30, 1947. 77. DUBITOIR, S. M. An evatuation of skin grafts for hand coverage. J. Bone @ Joint Surg., 34A: 81 I-819, 1952. 78. WEBSTER, G. V. and ROLAND, W. D. Skin grafting the burned dorsum of the hand. Ann. Surg., I 24: 449-462, 1946.

92. 93. 94. 95,

96.

1952. GOLDNER,,J. L. Deformities of the hand incidental to pathoIogica1 changes of the extensor and intrinsic muscle mechanisms. J. Bone TV Joint Surg., 35A: I 15-131, 1953. YOUNG, F. CicatriciaI contractures of the thumb. Surg., Gynec. @ Obst., 89: 264-270, 1949. MITHOEFER, J. Injuries Iimiting the mobility of the thumb. Am. J. Surg., 79: 399-404. 1950. HOWARD, L. D. Contracture of the thumb web. J. Bone eY Joint Surg., 32A: 267-273, 1950. S~ooc, T. Dupuytren’s contraction with special reference to aetioIogy and improved surgical treatment. Acta cbir. Scandinau. (suppI. 139), 96: 1-190, 1948. STEINBERG, C. L. Tocopherols in treatment of primary fibrositis. Arch. Surg., 63: 824-833,

‘951. 97. CLAY, R. C. Dupuytren’s contracture: tibroma of the palmar fascia. Ann. Surg., 120: 224-23 I, 1944. 98. ASKEY, J. M. The syndrome of painful disability of the shoulder and hand complicating coronary occlusion. Am. Heart J., 22: 1-12, 1941. 99. KEHL, K. C. Dupuytren’s contracture as seque1 to coronary artery disease and myocardial infection. Ann. znt. Med., 22: 213-223, 1943. 100. Ross, J. A. and ANNAN, J. H. Dupuytren’s contracture. Ann. Surg., 134: 186-194, 1951. _ IOI. TANZER, K. C. Dupuytren’s contracture. New England J. Med., 246: 807-813, 1952. 102. HAMLIN, E., JR. Limited excision of Dupuytren’s contracture. Ann. Surg., 135: 9497. 1952.

480

Surgical 103. KING, R. A. Vitamin E therapy in Dupuytren’s contracture. J. Bone CY Joint Surg., 3rB: 443. 1949.

I 04. HORWITZ, T. The significance of the venous circu-

105. 106. 107.

108.

109.

I IO.

I I I. 112.

I 13.

Iation about the elbow in the pathomechanics of VoIkmann’s contracture. Surg., Gynec. @ Obst., 74: 871-875, ‘942. GRIFFITHS, D. L. Volkmann’s ischaemic contracture. Brit. J. Surg., 28: 239-260, rg4o. FOISIE, P. S. Volkmann’s ischemic contracture. New England J. Med., 226: 671, 1942. CRYSTAL, D. K., BURGESS, E. and WANGEMAN, C. Thrombectomy in Volkmann’s contracture. New England J. Med., 247: 1o15-1017, 1952. CKEGAN, .I. C. Prolonged traumatic arterial spasm after supracondylar fracture of the humerus. J. Bone &+Joint Surg., 33B: 363-364, 1951. GRIFFITHS, D. L. Volkmann’s ischaemic contracture. EditoriaI. J. Bone CT Joint Surg., 33B: 29!?3oo, ‘95 1. HORN, J. S. and SEVITT, S. Ischaemic necrosis and regeneration of the tibialis anterior muscle after rupture of the popliteal artery. J. Bone CYJoint Surg., 33B: 348-358, 1951. NISBET, N. W. Volkmann’s ischemic contracture benefited by muscle-slide operation. J. Bone CY Joint SUrg., 34B: 245-247, 1952. PARKES, A. The treatment of estabIished VoIkmann’s contracture by tendon transplantation. J. Bone H Joint Surg., 33B: 359-362, 1951. THOMPSON, S. A. and MAHONEY, L. J. VoIkmann’s ischemic contracture and its reIationship to fracture of the femur. J. Bone @Y Joint Surg.,

33B: 336-347. 1951. I 14. LEBOLT, F. L. The use of capsuIectomy and arthroplasty for limitation of finger motion. Surg., Gynec. 8 Obst., go: 103-107, 1950. 115. MUELLER, G. M. Arthrodesis of the trapeziometacarpal joint for osteoarthritis. J. Bone CY Joint Surg., 31B: 540-542. 1949. I 16. GERVIS, W. H. Excision of the trapezium for osteoarthritis of the trapezia1 metacarpa1 joint. J. Bone FY Joint Surg., 31B: 537-539, 1949. I 17. LEWIN, M. L. PartiaI reconstruction of thumb in a one-stage operation. J. Bone Ed Joint Surg., 35A: 573-576, ‘953. I 18. GREELEY, P. W. Reconstruction of the thumb. Ann. Surg., 124: 60-70, 1946. I 19. KELIKIAN, H. and BINTCLIFFE, E. W. Functiona restoration of the thumb. Surg., Gynec. TVObst., 83: 807-814, 1946. 120. BUNNELL, S. Digit transfer by neurovascuIar pedicle. J. Bone e’p Joint Surg., 34A: 772-774, 1952. I 2 I. MARBLE, H. Persona1 communication. I 22. CLARKSON, P. Harrison-Kennard Oration. Boston City Hospital, January 18, 1954. 123. GRAHAM~ W. C., BROWN, J. B. and CANNON, B. Elongation and digitization of first metacarpa1 for restoration of function of hand. Arch. Surg., 61: 17-22, ,950. I 24. HIGGINS, G. A. Reconstruction of the hand foIIowing Ioss of aII digits. Surgery, 32: 712-714, 1952. 125. BARSKY, A. J. CongenitaI anomaIies of the hand. J. Bone TVJoint Surg., 33A: 35-64, 195 I. 126. WHITE, J. W. and JENSEN, W. E. The infant’s

Review persistent thumb-clutched hand. J. Bone
Hand

Surgery

W. W. L., MARAIST, F. B. and BRAATEN, 0. M. Treatment of frostbite with DarticuIar reference to the use of adrenocorticotroph c hormone (ACTH). New England J. Med., 247: 191-200, 1942. ITO. WARREN, R. and LINTON, R. R. The treatment of arteriat embotism. New England J. Med., 238: 421-431, 1948. 15 I. SILBERT, S. Etiology of thromboangiitis obtiterans. J. A.M. A., 129: f-12, 194~. 152. HAMLIN, E., JR., WARREN, R. and KENNARD, H. E. Thromboangiitis obliterans. New England J. Med., 241: 849-852, 1949.

153. GRANIT, R., LEKSELL, L. and SKOGLUND, C. R* Fiber interaction in injured or compressed region of nerve. Brain, 67: 125-140, 1944. 154. ROSENBLUETH,A. The stimmation of myelinated axons by nerve imputses in adjacent myehnated axons. Am. J. Pbysiol., 132: 119, 1941. 154. DOUPE, J., CULLEN, C. H. and CHANCE, G. Q. Post-traumatic pain and the causalgia syndrome. J. Neural., Neurosurg. 0 Psycbiat., 7: 33-48, 1944. 156. SHUMACKER, H. B., JR., SPEIGEL, I. J. and UPJOHN, R. H. CausaIgia. Surg., Gynec. ~3’ Ok., 86: 76-86, 1948.

149. GI.ENN,

A GOITER in the posterior mediastinum is very rare, but invariably it is derived from a cervical goiter even when connective fibers are no longer present. Such a “fake accessory goiter” usuaIIy Iies directIy in front of the spina coIumn and especiaIIy to its right side because of interference to its growth to the Ieft that is offered by the arch of the aorta. The superior vena cava and ascending aorta are invariabIy in front of it and aImost always the trachea and esophagus aIso lie anteriorly. Hence the best approach to this growth is the transthoracic one. (Richard A. Leonardo, M.D.)

482